All-Hazards Mitigation: Active Shooter Incidents

19-Aug-2015

Scenario: At 2200 hours on a Friday night, the alarm sounds for a possible violence response: “Engine, Medic, Battalion, respond to a movie theater.”

En route, dispatch updates advises multiple calls and multiple patients. The time has passed to preplan an immediate action plan. Is this a mass casualty incident (MCI)? Why isn’t it an active shooter response?

When the fog of uncertainty settles, details will emerge, and pictures will start to develop. The chance that this is exactly you have planned for is not good, but your plan is good, establishing a firm foundation on which to respond to this threat.

Many factors can affect the outcome of this event. Some we can control, and some we cannot. Having an early understanding of the problem is paramount, but it is not always easy. Sometimes, callers do not paint a realistic picture, dispatchers do not always pick up on the extent of the problem, or we just “drop the ball.” We can only affect the latter.

An active shooter, as defined by the Department of Homeland Security, is “an individual actively engaged in killing or attempting to kill people in a confined and populated area. In most cases, active shooters use firearm(s) to kill indiscriminately: “…Typically, completely devoid of pattern or method to the selection of victims although murder may occur during a rampage shooting.”

They will not stop until they are either killed or run off by law enforcement (LE) or have killed themselves. They differ from typical shootings in that they are ongoing dynamic event which occur typically in large buildings, schools, theaters, malls, and so on, but they could easily happen in residential neighborhoods.

These incidents require a paradigm shift in the fire service’s way of thinking. Many years ago, much of the fire service was comprised of veterans of the World Wars, Korea, and Vietnam; men accustomed to taking charge in the face of uncertain odds and a determined enemy. The 1970s and 1980s saw a shift toward specialized reactions to high-risk events to affect responder safety. The shootings at Columbine High School in Colorado showed the nation that the mindsets that were taught and reinforced in first responders do not work effectively in these types of incidents. Change comes slowly, often painfully.

As a result, most fire agencies began adopting policies of staging and standing by for LE for anything that sounded even remotely “violent.” It has now come to the extent that the fire service stands by for LE on an 80-year-old female whose family is at scene and feels she is suicidal. So, the zero-risk mentality has almost reached the apex of the swing to the left.

How does this affect our response to an active shooter incident? It is different, right? You have indoctrinated probies, officers, chiefs, and all those in between that their safety is always first. Is it not worth risking even on an 80-year-old woman whose family is with her? Now, you expect them to make the decision that they will now be exposing themselves to a very real and imminent threat of violence?

Just as it is with a residential fire or an auto extrication, how the scene unfolds is laid out in the first moments of the response. Have additional resources been called? Where do you stage them? What will be the ingress and egress? Who are the rescue crews?

This is an active shooter scene. LE will be here and respond to the threat. How we respond to the rescue depends on the relationship, training, and coordination with them. Just as our first-arriving units determine how we respond to the scene, the same goes for LE; their first-due will be forming hunter teams to find and eliminate the threat. They will not be treating anyone. Their job is ending the violence. As they push through, the building zones will go from hot to warm. Make no mistake, this is a fast primary for them. It can rapidly switch to hot again. At some point, one of the follow-on officers will have to assume command. This is LE’s Achilles Heel, and they are aware of it.

Here in Pierce County, Washington, we are fortunate to have a good relationship with LE agencies. These agencies very aggressively teach and practice the active shooter response. They also teach their officers the importance of early establishment of the incident command system (ICS). Without this, everything else is academic. This is where the fire service has the edge. We do ICS often and well, by sheer volume. It is up to the fire department’s incident commander to look for the LE command early in the incident and establish a unified command. This won’t happen immediately, but it needs to be on the heels of “immediately.” The deployment of rescue teams is contingent on unified command green lighting the operation.

Many crews do not need prompting to rescue victims in these circumstances, although some do. This is where the organization has to be behind the active shooter rescue team concept. The International Association of Fire Fighters position statement on tactical emergency medical services (EMS) and rescue teams has come out in support. Fire and Life Safety Initiative 12 has recognized the need for a unified coordinated response. This must be driven from the top down.

It is all well and good to establish treatment and transport, but just as in war, even with air supremacy, you still have to put boots on the ground. Crews still have to go in and bring out the wounded. You hear “risk a lot to save a lot” in conjunction with fire victims. These scenarios are not new, but they are new to this generation. There needs to be a top-down organizational lead that establishes how we respond to these scenarios, and it needs to be practiced. That means that with LE, all the players are in the same sandbox, not just random chiefs writing articles and serving platitudes; it has to be practiced on day-to-day operations. This has been our “secret ingredient” for more than a decade; we have departments trying to stay ahead of the curve and work together, not just around the table but on the street as well. Our active shooter rescue team protocol is unique in that it is not one-sided; there is by-in by the fire and police chiefs, and it is taught by LE and firefighters to firefighters and patrol officers (to the extent that budgets allow us to train together).

We put together crews of two to four firefighters with a LE escort of two to four patrol officers. Ideally, it would be four and four, but we do not operate in an ideal world, nor do we always have ideal staffing. You have to have a plan, and your plan must be flexible. Circumstances can and will change quickly. There is an understanding of the level of risk.

Fire is there to do what we do best: Pick up and move people. We will only provide treatment to immediate life threats that we can manage quickly (less than a minute or two). As a fire/EMS service, we respond to aid calls every day that require us to pick up and move people, typically in less than ideal circumstances; this is our primary role in the active shooter rescue. The more efficient we are at packaging and moving victims in these situations, the greater their outcomes, and the less exposure to the incident for our crews and LE.

We need to train on these rescues and have a protocol in place. If you were to call in a fire crew to extract a shooting victim from inside a structure, what do you think they will bring with them? As a fire/EMS service, we are trained and conditioned to never show up empty handed. Crews will bring backboards, C-collars, monitor, airway and trauma bags, and so on. In my county for this mode, we have set up an exception in protocols here in the county. Typically, in trauma calls, C-spine precautions must be followed. When this response is initiated, crews in our deployment plan will only bring the basics for the problems that we are likely to encounter and can solve. Speed and efficiency are your security. It is no different than if you found a man down in a structure fire. You would not take the same C-spine precautions that you would on a stable auto accident. It is a hostile environment, so we make exceptions.

Once you have removed patients from this hostile area, revert back to the standard of care. So, why would you behave differently in at an active shooter incident? Let’s say that victims have jumped from a high rise that was set ablaze by the “bad guys.” The entire area is potentially hazardous. When we move in to extract these victims from this active shooter environment, our goal is the same as in a normal fire: Move them to a safe area (get them off the “X”) where we will then revert to our standard of care. This is the goal of the rescue teams.

We follow the treatment guidelines of the Tactical Combat Casualty Care committee, which has become the Tactical Emergency Casualty Care for the civilian sector. Their recommendations are backed by years of actual combat medicine, both practical and antidotal. Those with a service background are familiar with the “CABCs.” It has been revised to Massive Hemorrhage, Airway, Respiration, Circulation, and Hypothermia (MARCH). We have packaged response bags (MARCH bags) based off the algorithm to treat three to five casualties. These bags have been placed on our battalion chief’s and manufacturer's statement of origin vehicles. As we have taught other agencies in the county, we have supplied them with these bags. They are not the perfect or necessarily the best way, but it was a start.

The MARCH Bag provides the hemorrhage control, which will be the primary treatment that will have a definitive effect in this environment. When the team comes across a victim, they conduct a rapid head-to-toe assessment to identify those life threats that they can definitively treat. Exsanguination from an extremity can be rapidly and definitively controlled by a tourniquet. We are not concerned with injuries that we cannot treat and/or are not imminently life threatening. After our assessment and rapid treatment, we need to get the victim out. We teach multiple methods for victim extraction. These are not “the way,” but are simply tools for the tool box.

In the “warm zone,” we are primarily concerned with the “M” and “A” of MARCH. These save penetrating trauma victims, the ones we can affect rapidly. As our security element surveys the area, they may recommend that we move into a room or around the corner before we treat victims. It is all fluid, and it is everyone’s job to be heads-up. It may very well be that the firefighters have more experience in this than the patrolmen that are escorting them. They may see the need to move to a more secure area prior to treating and need to feel comfortable making that call. Ultimately, security is LE’s job, but we must work as a team. This is the KEY, and it only comes from building these relationships before an incident.

Once we have done rapidly what we can for our patient(s), it is time for the extraction. LE trusts us to do our job, and we trust them to do theirs. So, now it is time to buckle down and take out as many victims that we can, moving rapidly and effectively. This depends on your environment; equipment; size of patient(s); and, ultimately, your fitness. Crews need to be mentally prepared for what they will face and physically prepared to carry it out. It is demanding to drag a 200-pound man several hundred meters. Have you practiced? Is that hour on the treadmill cutting it? What are your options?

Earlier, I described an active shooter. In a broad sense, it is based on scale. Our first-due is in a lively part of town. Our citizens don’t always tell us—let alone LE—the truth. It happens frequently that we arrive on scene of a shooting or stabbing where it turns out the bad guy was still in the area because the victim lied to LE. It has happens way too often that the bad guy decides to come back and finish the job. You cannot stop his intent, but you can minimize your exposure by knowing your job and be expeditious. Get in, treat life threats, package, and extricate rapidly, thereby reducing your exposure on scene. It is also good practice for the “big one.”

All this requires coordination between LE and fire. We must “play nicely together in the sandbox.” Too many departments have strained or no relationships. We all do different parts of the same job: Public safety. Working together on a daily basis is the only way that we will come together on large-scale incidents.

This is all about developing relationships. Over the years, we have developed working and teaching relationships, so it is not unusual to have LE teaching classes to firefighters on areas of their expertise such as excited delirium or the ever-changing world of drugs and the associated labs. Our firefighters, in turn, teach LE hemorrhage control and basic manual breaching (to name a few). We have worked and trained with agencies ranging from local fire/police, state patrol, the Federal Bureau of Investigations, and the U.S. Marshals. It is only by reaching out, training, and learning from one another that we will come together as the force multiplier that will have the greatest effect on our citizen’s survival at their moment of need.

When you were hired and put on that uniform and badge for the first time, what was it that made you proud? When you wear all your firefighter paraphernalia and drive around in your stickered truck, what is it you’re expecting from the citizens you serve? More importantly, what do they expect from you? When you signed on and were swore in, you signed a check. “The Man” put that check in a register. Someday may never come, but if it does, are you and your department prepared?

Originally posted by Chris Lorenz at FireEngineering.com