1. Active Shooter – EMS Response
September 21, 2016
UNYAN
Membership Meeting
Butch Hoffmann, BA, EMT-P

2. Today’s Objectives Active Shooter (AS) definition Provide AS behaviors
Describe AS situations - unusual
Provide case studies - lessons learned
Lessons learned from military combat
Today’s EMS AS tactics

3. US DHS – Active Shooter Definition
Where individual(s) is ‘actively engaged in killing or attempting to kill in a confined and populated area; in most cases, active shooters use firearms and there is no pattern or method to their selection of victims’. Active Assailant/Hybrid Targeted Violence Incident: One or more suspects, ongoing, random or systematic spree, any weapon with the intent to inflict mass casualties

4. A Type of Active Shooter
Domestic Attacker: Occurring more frequently!
American citizen
Born in another country, naturalized a U.S. citizen
Self-radicalized, no direct contact with terrorist organization
‘Inspired’ by terrorist propaganda i.e. ISIS
No combat experience or limited experience with weapons
Plan for other attacks

6. Other Types of AS Attackers
Int’l Terrorist Group
Extremists
Criminal
Gangs
Insider – mental health, anger or revenge, political / religious beliefs, notoriety

7. Targets of Opportunity
Commerce & Educational environments (~ 70%)
City streets
Military & Governmental properties
Private residences
House of worship
Sporting events
Health Care Facilities

8. Case Study Columbine High School, Colorado – April, 1999
Traditional Police Response
Perimeter Secured
45 minutes for SWAT to enter
13 victims shot and killed during SWAT mobilization
Shooters committed suicide upon police entry
Staged EMS
SWAT to clear school before EMS entry
One teacher died of hemorrhage. Preventable?

9. Following Columbine, 1999 Nationwide LE changed their AS SOPs
- First few officers form a response team
- Don’t wait for command level decisions
- Engage the subject(s)

10. Military Data:
15% of deaths in conventional combat are potentially preventable, COL Ron Bellmany, Vietnam War
Most common preventable causes of deaths
Exsanguination
Tension pneumothorax
Airway obstruction
Tactical Combat Casualty Care (TCCC) developed

11. Case Study Virginia Tech, Norris Hall – April, 2009
9:40 Shooting begins
9:50 ERTs with 2 SWAT Medics enter Norris Hall
SWAT medics use TCCC
Use multiple chest valves & tourniquets - saved lives
32 killed, 17 wounded, 6 inj’d from falling from windows
Rapid police entry forced action of shooter
Quick EMS presence saved lives
How many AS incidents are occurring annually in the U.S.? , , or

12. http://www. policeforum

13. Case Study Cinemark Century 16, Aurora, CO – July, 2012
12:30am Shooter releases tear gas first, then shooting begins
- 12 killed, 58 wounded
- No adequate access route for EMS
- LE transports victims to local hospital
- No triage tags, lack of staging
- No Unified CP during first hour
- AAR: LE needs medical care training

14. After Sandy Hook, Conn. – Dec. 2012
FBI, NAEMT, IAFC, ACS & the Military produced
Hartford Consensus: a nat’l strategy to enhance the survival rates in mass casualty shootings
Past practices of LE, Fire and EMS were not optimally aligned to maximize victim survival
Rapid EMS entry integrated with LE would save lives
Use military’s TCCC concept; by introducing a civilian version
Utilize Rescue Task Force (RTF) concept

15. Hartford Consensus (cont’d)
Critical Strategic Responses: ‘THREAT’ Principle
T = threat suppression
H = hemorrhage control
RE = rapid extrication
A = assessment by EMS providers
T = transport to definitive care

16. First Line EMS Providers
Tactical Emergency Casualty Care (TECC), civilian version of TCCC guidelines
Direct Threat Care: care under fire, LE only, hot zone
Indirect Threat Care: care with cover under relative safety, warm zone
Casualty Collection Points: casualties assembled for treatment & transportation
Evacuation Care: transitional EMS care

18. Tactical Emergency Casualty Care
Contact Entry Team - LE Only
Initial rapid police entry
Stop the bad guy
Bypass victims
Rescue Task Force (RTF)
LE escorting EMS/Fire/Rescue
Locate, stabilize, remove victims
Maintain situational awareness

19. Rescue Task Force Key Rapid EMS/Fire Interventions - open airway
- tourniquet application
- hemostatic gauze, pressure dressings
- chest seal
- chest decompression
- triage tag applied
- apply portable patient carrying device, i.e. extrication
straps, man-sack, Sked, reeves, backboard, etc.

20. Rescue Task Force Pro Rapid patient contact Saves lives Con EMS Risk
Lack of Equipment and Training
Lack of familiarity with LE tactics and movement
* Agency’s value judgment to acceptable risks

21. Conduct multi-agency planning committee mtgs:
- local, regional LE - jurisdictional & county EMS agencies - local Fire/Rescue agencies - local/regional EM - local 911/PSAP/dispatch/communication agencies - neighboring jurisdictions providing mutual aid - local school officials - major public venue reps: shopping malls, stadiums, entertainment, private industry

22. Multi-agency Planning cont’d
Education
Training – hands on skill development
Tabletop exercise
Full-scale exercise
Train regularly

23. AS Training: Warm Zone Stressors
Gas munitions
Fire alarms, sprinklers
Smells, smoke
Victims screaming
Death
Destruction, structural collapse
Detonations/gunshots
Darkness, confusion

24. AS Training/Planning
Establish CP, delineate safe zones, cover vs concealment
Stress keep access paths open for EMS
Establish multiple CCP/triage/transportation areas
Consider tactical physician at scene
Consider ‘cleanup/hydration’ station
CISM, EMS staffing at FACs
All RTF EMS personnel are trained & have exercised in AS scenarios
Maintain integrity of crime scene

25. Lessons Learned From AS Exercises
LE early representation in formal incident CP
Building side nomenclature, common terminology
Consider towing or pushing civilian vehicles out of way
Familiarization with other jurisdiction’s schools

26. Resources: Training DHSES State Preparedness Training Center (SPTC)
Advanced Active Shooter Scenario (A2S2)
AS Booklet: How to Respond
Fire/EMS Department Operational Considerations & Guidelines for AS & MCI
FEMA IS 253

27. “IT COULD NEVER HAPPEN HERE”
Kennesaw, GA; Washington, DC Navy Yard
Newtown, Connecticut; Omaha, Nebraska
Columbine, Colorado; Tucson, Arizona
Binghamton, NY; Brookfield, Wisconsin
Forth Worth, Texas; Salt Lake City, Utah
Blacksburg, Virginia; Boston, MA
Aurora, Colorado; Manchester, Illinois
San Bernardino, CA; Orlando, Florida
JUST HAPPENED AGAIN……

28. Thank you Questions???