Response protocol for active shooter type incidents?

[Monty 35]

Hearing about the Ohio school shooting made me think.

First off, I'll say that I'm not an active EMS provider. However, I was wondering if any of the organizations have a specific or general procedure for this type of event? Or would it be a spur of the moment, hotline type incident and an all call to everyone?

I'm sure the local schools have policies and have worked with PD, but have they worked with EMS? What about a shooting at a community event, similar to Tuscon AZ? In most areas, a school shooting would probably have significant manpower issues given that it is most likely to be during the typical school / work day.

Hopefully others have already thought about this .....

[Guest alsfirefighter]

Sadly, most have not worked with or have plans with PD. Our PD has 3 tactical medics who train constantly with them but if it becomes a large scale event they can easily become overwhelmed. I still have colleagues when the discussion comes up to have a policy and plan and that it needs to involve all emergency services still have the stage and wait concept..which goes against the after action recommendations post Columbine HS shooting. It all starts with communication and understanding why time is important with such incidents if they do occur. If you look many of these do not happen in urban settings...don't think it can't happen to you.

[38ff 250]

I was involved with an Active shooter training scenario a few weeks back in Albany that trained NYSP MRT and other local agencies. As far as the whole thing is concerned, it is VERY VERY manpower intensive, and you need to let the PD do their job, clear the rooms/building, THEN AND ONLY THEN you can do yours as an EMT. PD needs to sort out the good guys from the bad, and that all takes alot of time and manpower.

Edited February 28, 2012 by 38ff

[Monty 35]

I was involved with an Active shooter training scenario a few weeks back in Albany that trained NYSP MRT and other local agencies. As far as the whole thing is concerned, it is VERY VERY manpower intensive, and you need to let the PD do their job, clear the rooms/building, THEN AND ONLY THEN you can do yours as an EMT. PD needs to sort out the good guys from the bad, and that all takes alot of time and manpower.

Fair enough. However, I was thinking of EMS manpower. In a typical suburban / rural area, how long is it going to take to get enough resources to handle 5-10 patients (with physical injuries)? And numerous more in shock?

How are these resources going to be organized / staged / utilized etc.

It would seem to make sense for a countywide protocol - however, of course in NY (most) everything is Home Rule ....

[ny10570 745]

Fair enough. However, I was thinking of EMS manpower. In a typical suburban / rural area, how long is it going to take to get enough resources to handle 5-10 patients (with physical injuries)? And numerous more in shock?

How are these resources going to be organized / staged / utilized etc.

It would seem to make sense for a countywide protocol - however, of course in NY (most) everything is Home Rule ....

Its no different than a fire of traffic incident. Unless you're getting involved with tactical medicine you stage and wait for PD to start removing victims. Then triage and transport begins.

[antiquefirelt 994]

PD needs to sort out the good guys from the bad, and that all takes alot of time and manpower.

This has been identified as part of the problem. While we all understand the need to protect further persons from being in harms way, denying medical care to wounded has a serious consequence, tie that to school aged children and you have the recipe for tragic disaster with huge potential outfall. A more proactive response has been cited many times. Somehow LE must be more aggressive even with less personnel and allow or facilitate a rapid extrication of known victims.

[Goose 188]

Fair enough. However, I was thinking of EMS manpower. In a typical suburban / rural area, how long is it going to take to get enough resources to handle 5-10 patients (with physical injuries)? And numerous more in shock?

How are these resources going to be organized / staged / utilized etc.

It would seem to make sense for a countywide protocol - however, of course in NY (most) everything is Home Rule ....

Its a high profile event so the manpower will crawl out of the wood work, for sure. Now, competent manpower becomes a different story.

[voltage1256 42]

Not to change the subject here but I was surprised by how well prepared the school was for an incident such as this and how much they encouraged Emergency Service personnel to train for an active shooter. When I was in High School not long ago at all there was no communication between local LEO, FD, EMS and as far as the school was concerned as it appeared to me as a student, they thought locking classroom doors and shutting the lights off within what ever the allotted time was sufficient enough. The attitude of it will never happen to us has become far to common and far over thought IMO.

A situation like this are a Law Enforcement matter, but as many have stated above me there needs to be the thin line where EMS is just as involved.

Hopes & Prayers for the people of Chardon.

[v85 212]

In the Ohio incident, one news agency reported that the lockdown was lifted within 35 minutes of the initial report(s). But yes, there does need to be something done about the wait time for PD to secure a scene, and not just at active shooter incidents either.

But also, like ny10570 mentioned, a school shooting is generally not like HAZ-MAT/WMD incidents where you are going to have 100+ persons to be deconned, monitored and possibly transported. You generally are going to have a smaller number of victims with physical injuries, of course when you have agencies that can't even handle one call at a time, that doesn't mean anything.

In Orange County at least, BOCES and the school districts have put together a CISD team made up of guidance counselors, social workers and psychologists, so I imagine they will be handiling those in emotional shock, unless they were also displaying issues like hyperventilation.

[OoO 24]

This has been identified as part of the problem. While we all understand the need to protect further persons from being in harms way, denying medical care to wounded has a serious consequence, tie that to school aged children and you have the recipe for tragic disaster with huge potential outfall. A more proactive response has been cited many times. Somehow LE must be more aggressive even with less personnel and allow or facilitate a rapid extrication of known victims.

I disagree, I think the priority needs to be to neutralize the threat in order to prevent more people from becoming hurt. If police stop to care for or extricate victims, they are allow the shooter to continue and create additional victims.

This is no different than an MCI, there is no sense on working a CPR who will eventually die while other treatable critical victims deteriorate. If you stop to work on the already injured, you will allow others to become injured.

[SRS131EMTFF 471]

In Orange County at least, BOCES and the school districts have put together a CISD team made up of guidance counselors, social workers and psychologists, so I imagine they will be handiling those in emotional shock, unless they were also displaying issues like hyperventilation.

Anyone in emotional shock or having an acute stress reaction should be treated by EMS and observed by ED staff. I know some people will disagree with me, but I do not believe that a schools CISD team is prepared to deal with individuals in a catatonic state or a stupor that is associated with traumatic events like this one.

If an individual having an ASR is not able to process information properly and safely, they may not be in a state where I would feel comfortable with them or me signing an RMA form.

If nothing for no other reason, allowing EMS treatment will provide a continuity of care to the patient in an attempt to rebuild a social safety net and allow the individual to return to a new normal.

After having treatmented and transported victims from a school accident involving fatalities, the school and the parents were appreciative of the treatment that was provided by EMS/First Response. Obviously we treated those who were injured worst first, but we also ensured that all parties received at least some form of continuous initial care. It speaks volumes when we are able to care for everyone and not just those physically injured.

One of the most important lessons I have learned as a provider is the power and importance of PFA (psychological first aid).

Edited February 28, 2012 by SRS131EMTFF

[v85 212]

I would consider anyone catatonic or in a stupor to be exhibiting physical symptoms(ie... issues like hyperventilation) and would be treated and transported as such. I was referring to people who were not exhibiting any symptoms like that.

[x129K 1,393]

I can speak from experience, as I was the lead dispatcher on an active shooter two years ago or so (not in a school, but a municipal building with daytime staffing) ..ON THE DISPATCH end;

EMS and Fire units responding in for EMS duty/staging followed the orders of the police command on scene, relayed through the dispatcher.

I loaded up the assignment with a few extra buses, and dispatched them to the staging area as determined by the police IC.

There was no set protocol or alarm assignment.

Thankfully these additional resources were not needed.

[Guest alsfirefighter]

I was involved with an Active shooter training scenario a few weeks back in Albany that trained NYSP MRT and other local agencies. As far as the whole thing is concerned, it is VERY VERY manpower intensive, and you need to let the PD do their job, clear the rooms/building, THEN AND ONLY THEN you can do yours as an EMT. PD needs to sort out the good guys from the bad, and that all takes alot of time and manpower.

You have good points..but it depends on the system you have in place. We start triaging/treating life threatening injuries upon entry as areas are secured and held and as we encounter the injured. We also work with the SWAT team leader to establish a safe zone for staging area for injured. The thought process of above is exactly why Dave Sanders died from survivable wounds. With that said there are many different ways to handle these and you have to base your response on your system, working relationships and understanding. Outside of our area where things are so fragmented and the there's them and then there's us and who's sand box your in limits advancement for what is best for ALL to do their job and potentially save lives.

Littleton, CO now has the largest TEMS program in the country.

http://www.usfa.fema.gov/downloads/pdf/publications/tr-128.pdf

Very good document to read about the columbine incident and the lessons learned and recommendations for agencies for future incidents.

[Goose 188]

I disagree, I think the priority needs to be to neutralize the threat in order to prevent more people from becoming hurt. If police stop to care for or extricate victims, they are allow the shooter to continue and create additional victims.

This is no different than an MCI, there is no sense on working a CPR who will eventually die while other treatable critical victims deteriorate. If you stop to work on the already injured, you will allow others to become injured.

I think you may need to reevaluate the way you're looking at this. I'm not sure anyone is advocating that a shooter or shooters not be apprehended, i think the key is that both the apprehension of the suspect or suspects, the orderly evacuation of those able to evacuate, and the initial treatment and and extrication of victims needs to occur simultaneously. Thus, there may be a greater need to have EMS interface w/ PD in these types of tactical situations.

I will be honest, and tell you that i would personally find it hard to simply leave a child who's the victim of penetrating trauma in a situation like this.

Those in Ohio lucked out - this nut bag seems to have been particular who he wanted to inflict harm upon, it looks like one or two others unfortunately were in the cross fire. After doing what he came there to do he booked...neutralizing any additional threat to the students in that facility.

[antiquefirelt 994]

I disagree, I think the priority needs to be to neutralize the threat in order to prevent more people from becoming hurt. If police stop to care for or extricate victims, they are allow the shooter to continue and create additional victims.

This is no different than an MCI, there is no sense on working a CPR who will eventually die while other treatable critical victims deteriorate. If you stop to work on the already injured, you will allow others to become injured.

The thinking on more rapid extrication of victims is not for the LEO's to do it alone, but instead to assemble some form of entry/clearing team that allows Fire/EMS to come in behind in the "cleared area" to begin care rather than acknowledge injured parties are inside but exclude them from immediate care. This takes a concerted effort for Fire/EMS and LE to sit down and discuss roles, responsibilities and risks. This is a classic risk/benefit analysis: The risk is putting personnel in danger of being shot, the reward is saving the lives of children. Remember we as Fire/EMS personnel assume a higher level of risk when we take these jobs.

None of this should be taken as a "just do it" but a discussion that should be undertaken given the high potential for fatal wounds left untreated while smaller communities attempt to secure large facilitation without immediate resources. There were many things that came out of Columbine that speak to this topic.

As an example of a similar school of thought I offer this:My community holds a large multi-day festival that culminates in a large parade in the beginning of August. The attendance in our downtown area is extremely high, with roads blocked and LE, Fire and EMS units staged all over. Last years event planning included an "active shooter" scenario taking place at a business on Main Street during the parade. The Trooper in charge of the tactical response refused to allow pre-staged Fire/EMS units to help move the crowd from the area of the shooter scenario while being severely understaffed to engage the shooter. The thinking was that they couldn't use anyone but LEO's to remove the citizens, yet the answer was to not move them as the shortage of officers required they address the shooter first. Our contention was that we have staged personnel in the immediate area who do assume a level of risk with regard to protecting human life and these personnel could in fact help rather than be sidelined while civilians were going to be left to fend for themselves. The point is we are not LEO's and should not do anything that would actually harm their efforts, but they also need to let us do our jobs even at some risk when the benefit is deemed high.

[v85 212]

Not to take this thread too far off topic, but what happened the idea of tactical medics? I remember reading a couple of years ago that more places were implementing them and they had a wide variety of "styles" from police officers were only there to treat other police officers to EMS personnel who were sworn in as special police officers and given firearms training who would attend every SWAT callout and treat everyone.

Did this idea die out with the budget cuts of recently? Is it feasable to implement something like that here?

[Guest alsfirefighter]

Not to take this thread too far off topic, but what happened the idea of tactical medics? I remember reading a couple of years ago that more places were implementing them and they had a wide variety of "styles" from police officers were only there to treat other police officers to EMS personnel who were sworn in as special police officers and given firearms training who would attend every SWAT callout and treat everyone.

Did this idea die out with the budget cuts of recently? Is it feasable to implement something like that here?

There is much debate within the LE community about how best this can be accomplished. Again as I pointed out...its very difficult to crack traditions and mind sets here in the northeast. Not so much so in the south and west. There are debates about the merits of having LEO's trained in EMS...time, money, experience...vs having allied agencies like my TRT does...armed vs. unarmed...here in NY liability is always an issue, getting past the ego part of it...etc. Then there are the tactical debates on it...role confusion for LEO's gun or medic?

OOO...not sure what you've read about active shooters etc...and to be honest I wonder about what MCI training you received. This is very simple...you're talking about CPR...apples and oranges...I'm not working a cardiac arrest as a tactical medic...unless its one of my guys and time allows. "If you stop to treat the already injured...more will get injured"...well if you don't have anyone treating the already injured...you will then have a lot in cardiac arrest. X A B C....the rules of trauma are changing....stop bleeding rapidly...even over airway. Exsanguinating hemhorrage....airway...breathing...circulation

[v85 212]

I know this would probably be impossible in NYS because of liability, but I know that tourniquets and quick-clot type bandages are in the BLS protocol, so even if police just carried them to throw to a downed student or staff member the encounter while clearing the building. It's not much, but at least it would be SOMETHING to buy time until the scene can be properly secured for EMS to come in.

Edited February 29, 2012 by v85

[gmspro 3]

Sir,

You have raised a FANTASTIC question! As an active EMS person in the NY and Westchester County area for decades, it is a topic I have raised to many. There is a state of mind, especially in the Westchester/Rockland areas and areas north; that is "It could never happen here." So many EMS providers, even at this juncture in our post 9/11 world, think that because its not "da bronx" or "brooklyn"; that such a type of shooting will happen in Westchester or surrounding communities. That mindset is part of one of the issues that keeps Westchester from becoming an even more progressive and formidable, cohesive set of providers. Westchester, for example, actually presents a number of serious issues in large-scale EMS incidents. Westchester is extremely agency-disassociated; in that you have areas that are served generally by three types of services; paid EMS (most of the paid services are either by a "for profit" agency or known as an ambulance company that is contracted to provide BLS or ALS services to a community, a combination of paid staff and volunteers and some all volunteer. Because you have so many differently run agencies and there is still a lack of true incident orchestration for EMS incidents; it is usually done on the fly. The County has not made great effort to establish a solid EMS command structure that is understood by its providing agencies. They have left much of it up to the individual agencies and with forty-five EMS providing agencies, that leaves way to many cooks in the kitchen. The other issue is experience. You run the mill of different experience levels in the county. Some providers have extensive experience, some in urban environments where large-scale MCI's are normal. But often because of the difference in the area and suburban settings; many volunteers are not as practiced in the sheer amount of patients or the level of injuries that may be encountered. Additionally and not as a matter of fault, but because MCI's are not as frequent in the suburban areas, as opposed to urban environments where there are MCI's daily; the lack of experience in this area makes it even more essential for county providers to be prepared. The County does need a more intensive EMS program and exercises should be mandatory to meet the needs of the post 9/11 counter-terrorism world that we live in. More EMS providers need to be introduced to tactical EMS, working directly with the law enforcement providers around the area. This would mean S.W.A.T. teams from agencies in their local area, as well County, State and Federal units. It would be a great service and experience in the horrific event that what happened in Ohio, happens locally.

There should be at least a bi-annual drill for as many agencies as possible including EMS, Law Enforcement and Fire. There should be County-wide protocol set up by municipality, taking into account the amount of resources the agency has and the expected response of the other public safety agencies. There should be specific plans laid out to act as a guide of things to remember; staging areas, landing zones, resources in the immediate vicinity that may be forgotten in a crisis situation. There should also be a pre-planned Critical Incident Stress Debriefing that is MANDATORY for all providers once the incident has completed its de-escalation phase.

Westchester County and the surrounding counties all the way out to Long Island have outstanding volunteer EMS providers. Westchester County for example, in an effort to fully support their EMS providers and give even more support to a major incident; should have a greater number EMS Battalion Coordinators with a larger role in the EMS response of the County. There are ten Fire Battalions Coordinators and only three EMS Coordinators. WIth a major airport, miles and miles of roadway, industry, Indian Point and all of those who reside in the County; it is time to step up the adaptability and efficacy of Counties everywhere. There are grants through DHS and FEMA that can be utilized to augment current holes in EMS Incident Command. Sometimes, there are those who want things to be like they were many years ago, and we just don't live in that world anymore. There also needs to be better credentialed EMS leaders who have direct experience in Incident Command on a large scale, and not just someone who might have been appointed because of their popularity. It is not an insult; but some have no concept of when to admit that there are bigger problems in front of them, and teamwork is essential. It is important to put down the ego's and arrogance for the benefit of patients, and come together as a family of providers, evaluate each others strengths and weaknesses and build on them.

[helicopper 1,050]

1. The focus of this thread is - and rightfully so - the EMS response to an active shooter, not the law enforcement response or their tactics.

2. EMS should be more proactive and seek out the schools and the law enforcement agencies to develop realistic pre-plans, training, and perhaps most important... exercise the plans and training! We don't exercise our services well at all but that's a topic for another thread. If we in EMS continue to wait for someone else to bring us to the planning table, we may still be waiting when the call comes in.

3. EMS (and all other resources) should not respond unless dispatched and should respond to the designated staging area only.

4. EMS needs to be aware that suspects may be exiting the scene with real victims so extreme caution must be exercised at all times. Consider additional PD to support and safeguard the EMS operation until the entire scene is secure.

5. Recognize that the situation is very dynamic and information may change dramatically and quickly. Be flexible, be safe, and avoid tunnel vision!

6. Keeping with the all-hazard approach to things, as others have suggested, conduct meaningful MCI training, triage training, and train on how to evacuate patients quickly and safely!

7. It must be clearly recognized and accepted that PD is in charge of the scene and orders must be followed for everyone's safety, not because of egos or attitudes.

A couple of random thoughts on some of the other comments in this thread:

On the subject of tactical triage, in an active shooter scenario we can't stop to triage, treat or do anything else. The focus must be on eliminating the threat to others and controlling the scene so all the victims (the obvious ones as well as those who may not be readily observed) can be properly treated.

Tactical medics are a great resource and should be commonplace. Unfortunately, for many of the reasons we've heard already they're not (egos, turf, $$$, attitudes).

Tourniquets and quick clot may not be part of BLS protocols but they can (and in many cases are) used by tactical teams.

Good discussion. Thanks for starting this thread!

[EMT-7035 4]

I know this would probably be impossible in NYS because of liability, but I know that tourniquets and quick-clot type bandages are in the BLS protocol, so even if police just carried them to throw to a downed student or staff member the encounter while clearing the building. It's not much, but at least it would be SOMETHING to buy time until the scene can be properly secured for EMS to come in.

Aside from the liability of it, as it is now, tourniquets are a last resort and great care must be taken when deciding to apply one. If you were to as you say, "throw them to a downed student", several problems may arise. Even assuming they are able to determine how it works, if it's their only option, they may apply a tourniquet to a limb that would've survived even if it had to wait an hour for EMS and assuming that same hour wait time, that limb has little (if any) chance of being recovered. It's like the same idea as poorly performed CPR, it can do more harm that good unless properly trained.

[v85 212]

These are the new protocols for external bleeding. From what I am hearing, they are finding out from the military hospitals that use of a tourniquet does not equal automatic loss of that limb, hence the reason why it is back in the protocol. While the idea that I mentioned might be "extreme", something does need to be done, or else an EMS and LE agency may find themselves on the witness stand trying to explain to 12 citizens who know nothing about emergency services why "nothing was done" while children bled out.

II. Control bleeding by:

A. Immediately applying pressure directly on the wound with a sterile dressing.

NOTE: If available and bleeding is severe, a hemostatic gauze dressing

should be applied directly to the bleeding site simultaneously with

direct pressure.

B. If bleeding soaks through the dressing

, apply additional dressings while

continuing direct pressure.

Do not remove dressings from the injured site!

C. Cover the dressed site with a pressure bandage.

III.

If severe bleeding persists from a limb, apply a tourniquet just proximal to the bleeding

site. If severe bleeding still persists, a second tourniquet may be applied proximal to the first

tourniquet. Record time tourniquet was secured and document near the tourniquet site.

IV.

If severe bleeding persists from the trunk, neck, head or other location where a

tourniquet cannot be used

hemostatic gauze dressings should be used.

[ny10570 745]

Just tossing a tourniquet to someone is useless. If they had any clue how to use one the pt would already have a belt or something else put in place.

As it was explained to me NYPD would use available officers not involved in the search to remove victims to EMS. This to me seems the most practical short of adding a larger tactical EMS component.

[Guest alsfirefighter]

Aside from the liability of it, as it is now, tourniquets are a last resort and great care must be taken when deciding to apply one. If you were to as you say, "throw them to a downed student", several problems may arise. Even assuming they are able to determine how it works, if it's their only option, they may apply a tourniquet to a limb that would've survived even if it had to wait an hour for EMS and assuming that same hour wait time, that limb has little (if any) chance of being recovered. It's like the same idea as poorly performed CPR, it can do more harm that good unless properly trained.

Actually as pointed out already...they're almost front line now. Your information is outdated and incorrect. Even minimal bleeding for an extended period of time is critical. There are several case studies of LEO who received what was thought to be a "simple" GSW who later died. Studies from combat areas have shown that tourniquets can be left applied for several hours without any adverse effect to limbs. They've been around for a really long time...napoleon era military used them...in fact all military personnel who are "in country" are issued a CAT Tourniquet. They're designed to be applied with one hand. If you can train the entire Marine Corps to put it on...you can give verbal directions or the person who has to use it can follow the directions in the package. Using your example of having a tourniquet applied to a "limb that would've survived if it had to wait a hour for EMS," I would venture to think that if a tourniquet is even being considered it is after they've applied direct pressure or the trauma is that significant that they could have multiple small wounds...ie shrapnel, bullet fragments, other items that may have become projectiles (wood, glass, etc). I carry 4 CAT's in my SWAT vest....and now finally have 2 of them in my trauma bag right next to our Celox and Quik Clot.

I'm not sure where you've been told along the way that there is liability for using tourniquets. They are used almost every day in hospitals from community ones to trauma centers most often in the OR to limit bleeding during procedures on extremities.

And improper or inefficient CPR will actually not do anymore harm..you can't get deader. What it does do is already reduce the very low statistical chance of a resuscitation.

As a side point...any agencies who are looking into purchasing commercial tourniquets...the CAT T is the one used by the military. There are others out there but the CAT is proven and being they are the military provider you can ensure they are military grade. Just make sure you get them from the company. There are generics out there and other tourniquets that look similar but they're reports of the stitching failing when tightened, the windlass not staying secured etc. The CAT is also NTOA (national tactical officers association) and NYTOA (New York Tactical Officer Association) recommended.

In regard to hemostatics...I prefer Celox...but Quik Clot is a close 2nd with their new formulation and gauze. Proper training is key here..its not pour or wrap and forget...direct pressure must be used.

[JCESU 20]

This takes a concerted effort for Fire/EMS and LE to sit down and discuss roles, responsibilities and risks. This is a classic risk/benefit analysis: The risk is putting personnel in danger of being shot, the reward is saving the lives of children. Remember we as Fire/EMS personnel assume a higher level of risk when we take these jobs.

In theory that's very romantic. However the reality is that it is still an 'Active Shooter' situation and will be treated as such by law enforcement for a multitude of reasons. Sadly liability is what worries most at the upper part of the food chain. It is an explosive, emotional, dynamic and tenuous situation at best. It would be great to have EMS follow up the six as rooms/buildings are cleared, until a sleeper etc. shoots an EMT in the head while he/she is treating a patient in a hot zone. Then the order of the day will be 'How could the cops let EMS into an active shooter scene-what were they thinking?' It's not an insult to the victims or malfeasance by EMS that they be required to 'stage' until the 'all clear' is given. Being part of the same family, it would needlessly, make me give pause to rendering assistance to YOU, if wounded, rather than dealing with the threat(s) causing additional victims. These active shooter situations can be trained for and drilled over and over, with all the manpower that can be mustered on the day of the drill-to perfection. In reality if and when it does happen you will probably be at minimum manpower, with a one-thousand foot ceiling quashing medevac and half your transport equipment will be OOS. Active shooter situations are nasty, nasty business that can be summed up by saying they are more about what you shouldn't do rather than what you should have done and in the worst of circumstances. Each situation is unique and we all must stay fluid in addressing them in each encounter.

[EMT-7035 4]

Using your example of having a tourniquet applied to a "limb that would've survived if it had to wait a hour for EMS," I would venture to think that if a tourniquet is even being considered it is after they've applied direct pressure or the trauma is that significant that they could have multiple small wounds...ie shrapnel, bullet fragments, other items that may have become projectiles (wood, glass, etc).

I'm not sure where you've been told along the way that there is liability for using tourniquets. They are used almost every day in hospitals from community ones to trauma centers most often in the OR to limit bleeding during procedures on extremities.

And improper or inefficient CPR will actually not do anymore harm..you can't get deader. What it does do is already reduce the very low statistical chance of a resuscitation.

I think the point is here that just throwing supplies to untrained bystanders is not likely to solve any issues that wouldn't have been taken care of anyway. What I mean by that is, as mentioned previously, anyone with the training to determine that a tourniquet is needed would likely have made a makeshift one, or would identify themselves as being "trained". And this relates to the idea of applying pressure, anyone who has the training for a tourniquet would (hopefully) already have attempted applying pressure and other attempts.

And in terms of the use in the OR, again it comes down to training, we can (hopefully) assume that they are being applied as a last resort and that they are not going to be removed without necessary precautions. Who's to say that a bystander wouldn't take it off once they think the bleeding has stopped or be stupid enough to try to use in on their neck?

And in terms of the CPR example, I would agree that while they are dead, and dead is dead, as you mentioned, it can reduce the low statistical chance, generally considered more harm than good.

Edited March 1, 2012 by EMT-7035

[Bnechis 3,961]

There is a state of mind, especially in the Westchester/Rockland areas and areas north; that is "It could never happen here." So many EMS providers, even at this juncture in our post 9/11 world, think that because its not "da bronx" or "brooklyn"; that such a type of shooting will happen in Westchester or surrounding communities. That mindset is part of one of the issues that keeps Westchester from becoming an even more progressive and formidable, cohesive set of providers.

Agreed. 2 years ago at the NYS OHS conference, the State Police Superintendent present an Al-Qaeda training tape that was captured in Afganastan. It showed a training camp with an elementary school, that they were practicing attacking. He said, the most likely schools for an attack were elementary schools, that were close enough to the NYC media market and in smaller (& wealthier) communities that generally only had small police depts and no ESU/Swat.

They understand that the Bronx will have a high level rapid police response that is not available in Westchester, No. Jersey, etc. While this is a different type of incident, it shows the need for preparation.

Westchester, for example, actually presents a number of serious issues in large-scale EMS incidents.....Because you have so many differently run agencies and there is still a lack of true incident orchestration for EMS incidents; it is usually done on the fly.

Well said.

The County has not made great effort to establish a solid EMS command structure that is understood by its providing agencies. They have left much of it up to the individual agencies and with forty-five EMS providing agencies, that leaves way to many cooks in the kitchen.

The county has offered a number of training programs and the response from EMS has been ZERO. Since no one from EMS was willing to train at the FTC, they offered to bring that training to each EMS agency, and the response was ZERO. If the agencies are not willing to step up to the plate, you cant blame the county for not building a new stadium.

The County does need a more intensive EMS program and exercises should be mandatory to meet the needs of the post 9/11 counter-terrorism world that we live in.

It was tried with dozens of WMD & mass decon classes held in 2002/2003 with 9/11 fresh in everyones head and almost no EMS personnel showed up, we ran over a dozen seperate classes. How does the county make something "mandatory"?

More EMS providers need to be introduced to tactical EMS, working directly with the law enforcement providers around the area.

We have many EMS agencies that can not get an ambulance on the road in under 30 minutes for a heart attack. While EMS should have this type of introduction, their are a lot of more critical "failures" that need to be addressed 1st. You are suggesting we be able to run, when we still can only crawl (after 3 tone outs).

There should be County-wide protocol set up by municipality, taking into account the amount of resources the agency has and the expected response of the other public safety agencies. There should be specific plans laid out to act as a guide of things to remember; staging areas, landing zones, resources in the immediate vicinity that may be forgotten in a crisis situation.

There have been, since 1992 and they have been updated a number of times. Its clear that agencies do not know, want to know or shows them to their members.

Westchester County for example, in an effort to fully support their EMS providers and give even more support to a major incident; should have a greater number EMS Battalion Coordinators with a larger role in the EMS response of the County. There are ten Fire Battalions Coordinators and only three EMS Coordinators.

I AGREE. Infact, in 1992 the 1st true County EMS mutual aid plan called for 10 Deputy Coordinators. It took 10 years to get 1 and a few more to go to 3. Having enough EMS coordinators is more important than the fire coordinators, since most MCI's are done in 90 minutes or less, while most of the fire responses with coordinators are much longer. The need to arrive quickly for the MCI ones are more critical.

There also needs to be better credentialed EMS leaders who have direct experience in Incident Command on a large scale, and not just someone who might have been appointed because of their popularity. It is not an insult; but some have no concept of when to admit that there are bigger problems in front of them, and teamwork is essential. It is important to put down the ego's and arrogance for the benefit of patients, and come together as a family of providers, evaluate each others strengths and weaknesses and build on them.

Agreed, how does one do that with home rule?

[antiquefirelt 994]

In theory that’s very romantic. However the reality is that it is still an 'Active Shooter' situation and will be treated as such by law enforcement for a multitude of reasons. Sadly liability is what worries most at the upper part of the food chain. It is an explosive, emotional, dynamic and tenuous situation at best. It would be great to have EMS follow up the six as rooms/buildings are cleared, until a sleeper etc. shoots an EMT in the head while he/she is treating a patient in a hot zone. Then the order of the day will be 'How could the cops let EMS into an active shooter scene-what were they thinking?' It’s not an insult to the victims or malfeasance by EMS that they be required to 'stage' until the 'all clear' is given.

Your opinion is likely spot on in those areas where ESU or tactical personnel are not more than 30 minutes away. But in large portions of this country tactical ops are generally barricaded subjects as the time to assemble is far too long. In an active shooter situation where there's a large population exposed (such as a school or office building)by the time can be too great. This reportedly was a factor int he deaths of one or more victims at Columbine. It has nothing to do with "being benched" or feeling insulted, it has to do with taking calculated risks where the reward is great. Again, none of this should take place without an actual pre-plan worked out between all those involved to understad the responsibilities, roles and liabilities.

Your statement about liability, for lack of a better term as I mean no disrespect, is typical of much of the law enforcement community who when faced with a task, scenario or situation puts their liability questions in the priority one slot. It's not the fault of the individuals, yet a our culture who has put so much fear or legal reprisal that many key decision are based on liability. As those commanders in Iraq and Afghanistan who suffered under conditions that lawyers had to be consulted before making some key decisions.

[SageVigiles 1,194]

Take a look at this, regarding SWAT teams and Tac Medics

Columbine Timeline:

1110: Suspects arrive on campus

1119-1124: First 911 call for "sound of explosion" Shooting begins shortly after

1124: First School Resource Officer arrives on scene and engages suspects unsuccessfully (Does NOT pursue suspects into the building)

1133: Jefferson County SWAT Commander orders paging out of SWAT and Command Post

1149: Denver Metro SWAT Arrives on Scene

1206: SWAT makes entry behind cover of firetruck, begins evacuating patients while conducting search

1208: Suspects commit suicide

The suspects had already done the most damage before SWAT was even on scene. Hell, they killed themselves 2 minutes after the team entered. Some victims didn't get evacuated by SWAT until after 3PM. Unless you have a full time ESU/SWAT like some of the larger municipalities, your SWAT team isn't going to have time to get set up before the shooting ends. Neither is your Tactical Medic Team. Virginia Tech and so many other incidents have learned the same thing: Wait for SWAT doesn't work in an active shooter, unless you have a full time SWAT/ESU driving around waiting for a job.

The sooner PD can stop the threat, the sooner EMS can begin triage and treatment. IMO, there isn't time to stop and treat people. Stop the shooting and you will be able to SAFELY and effectively operate as EMS/Fire responders. This is not to take away from Tactical EMS at all, its definitely necessary in many instances and its an EXCELLENT program to have in place if you can have it. But as I understand it, the priority in an active shooter is not providing treatment, its ending the threat. JCESU or Helicopper or someone can correct me if I'm wrong, but that seems the most logical conclusion.

Maybe this is a good reason for a "Tactical/Active Shooter Incident Awareness" type course, so that the front line Firefighters and EMTs on every rig know what's expected of them at an active shooter incident and can begin setting up triage, treatment and transport areas. Knowing how and where to set up staging areas, knowledge of cover and concealment so you can avoid becoming a target. These are the things the everyday non-tactical responder can do to prepare for this type of incident.

And one more thing about staging. At Columbine the 2 shooters called false fire alarms for months before the incident to see where the FD and PD staged their units. They placed them the same spots almost every time. Guess where the two scumbags planted their bombs outside???

If you get the chance, read the book "Columbine" by Dave Cullen. You get a good picture of the lessons all the emergency responders learned at that incident. It would be folly not to use their knowledge.