Over a weekend in October 2010, approximately 120 members of the San Francisco Bay Area EMS community gathered in Alameda County to train in an "active shooter" scenario with 29 SWAT teams from around the world, including the national police force from Israel, a special security detail from Bahrain and the Knights of Justice from Jordan.
Dubbed Urban Shield, this SWAT training and competition, hosted by the Alameda County Sheriff's Department, presented its international contingent of special-operations teams with 30 different situations ranging from Columbine-style school shootings to hostages held on a commercial aircraft.
EMS teams of six worked four-hour shifts responding to scenarios involving up to 20 role players in a mock office shooting scenario. There were also about 20 EMS, FBI and other law enforcement checkpoint staff responsible for planning, logistics, a training module and evaluating the EMS teams rotating through with the SWAT units. EMS personnel were included in an MCI force-protection scenario in the office as integral members of the response team.
According to Jim Morrissey, prehospital care coordinator with Alameda County EMS and a tactical paramedic with the San Francisco FBI SWAT team, EMS was incorporated as an equal partner to help clarify the task of EMS on SWAT calls.
"The role of a SWAT medic is clear," Morrissey says. "What is less clear is the role of the supportive 'standby' EMS teams."
Despite popular perception, active shooter scenes are not always "hot" one minute and "cold" the next. Rather, says Morrissey, they are often "warm" for extended periods. During these times, EMS has historically been unable or unwilling to access the scene and start treating patients. By using SWAT to provide protection for EMS crews, patient care can be provided in a safe manner sooner than is common today.
Within the parameters of the exercise, the SWAT teams were provided with intelligence about a confirmed active shooter in a law office, with reports of people injured. The shooter was believed to be acting alone.
After entering the office and neutralizing the threat, members of the SWAT team escorted the EMS teams into the building to triage and perform emergent treatment and rapid extrication while officers maintained security. When the patients were packaged, EMS teams removed them to an external staging area, again under close-quarters protection.
What made this exercise different from current practice is that SWAT teams were required to think about treatment for injured parties as soon as the immediate threat (the gunman) was neutralized, rather than waiting for the entire building to be declared safe. Once safe ingress and egress for EMS was in place, crews were brought in to begin treatment.
"You don't want to be exchanging business cards the day of a disaster," says Morrissey. By training jointly in simulated conditions, SWAT and EMS have the opportunity to "iron out details then, not during a real event." Since tactical medics are present mainly to treat SWAT team members, EMS crews are better suited this way to treat other victims.
Morrissey stresses that he is not suggesting placing EMS in harm's way. Instead, he suggests that crews think of tactical teams "like another layer of personal protective equipment" when responding to MCI situations where the threat is unlikely to be present while people are dying.
Julie Beach, a paramedic in Alameda County, agrees with the idea: "If we can utilize SWAT in such a way that we can move our patients more quickly and get them to an ER faster, we could save a lot of lives," she says.
Morrissey points to a statistic showing the vast majority of active shooter situations are over within eight minutes. The perpetrator typically commits suicide or is killed by law enforcement within that time frame.1 By reducing staging times that can run up to several hours, Morrissey feels outcomes for time-sensitive patients can be improved. This theory makes sense considering that most patients in active shooter scenarios will be suffering from traumatic injuries, and prehospital times of more than an hour are associated with significantly increased rates of death.2
Cayce Justice, another Alameda County paramedic, cautions that such a response may not be appropriate for all EMS personnel.
"We need to have people trained to a level where they feel comfortable in situations like this," Justice says. "And we need to have a rapport with SWAT teams on a personal basis."
Beach agrees and adds that "Urban Shield could very well be giving us the opportunity to lay groundwork for closer integration between SWAT and EMS."
In the future, Morrissey expects a paradigm shift in both the EMS and SWAT communities. He sees that law enforcement is beginning to accept this new role in providing cover for EMS teams and hopes that EMS will embrace its possibilities as well.
"Urban Shield will continue to support this important aspect of emergency medical care in less-than-ideal situations," Morrissey says.
Such a situation was presented to Alameda County EMS crews during a recent wave of protests and civil disturbances. Tactically trained and equipped EMS personnel manned the front lines with police, extricating patients to "regular" crews at the hot zone/warm zone interface, which was secured by law enforcement. The warm zone crews ultimately extricated those patients, with law enforcement security, to the cold zone for transport. While not an active shooter situation, this event demonstrated the ability of law enforcement to provide force protection to nontactical EMS personnel to accelerate patient treatment on semi-secure scenes.
References 1. Force Science Institute. Ohio trainer makes the case for single-officer entry against active killers. Force Science News (serial online) 97, 2008. 2. Liberman M, Roudsari B. Prehospital trauma care: What do we really know? Curr Opin Crit Care 13: 691-696, 2007.
Patrick Lickiss, BS, NREMT-P, is a paramedic for Alameda County (CA) EMS and authors a blog at 510Medic.com.