As students at Marjory Stoneman Douglas High School eagerly prepared for Valentine’s Day celebrations on February 14, 2018, former student Nikolas Cruz was preparing to carry out a mass murder. He entered the school with an AR-15 rifle, killed 17 people, and injured 17 others.
An idyllic city bordering Coral Springs to the north and set near the eastern coast of Florida, Parkland is still reeling from the devastation, but its residents are as resilient as ever, and perhaps even more so are its first responders. In this exclusive interview Juan Cardona, EMS division chief of the Coral Springs–Parkland Fire Department, and Peter Antevy, MD, EMS medical director for Coral Springs Fire Department, share their seven most significant lessons learned when it comes to training for and managing mass-casualty incidents.
1. Not If But When
“A good lesson for the rest of the world: It’s not a matter of if. For me, it was always a matter of when,” says Cardona. As active-shooter events kept happening throughout the country, “The more prepared we got, the better I felt that when the moment came we would be ready to handle it. I think everything in the end played out, and that actually came true.”
A major factor that contributed to the number of lives saved that day was the strong collaboration between area law enforcement agencies and the fire department. Officers from Coral Springs, the Broward County Sheriff’s Office, and several other agencies, including SWAT medics, provided lifesaving treatments to victims at the point of contact while EMS staged outside the school.
“They didn’t save those tourniquets and chest seals for themselves—they applied them to those who needed them,” says Cardona. “They had been trained in trauma management.”
“That’s why every single person who came out of there with a severe injury and a pulse lived,” says Antevy. “They started treating them as they saw fit based on their training and with the equipment issued to them, so huge kudos to them.”
Law enforcement doesn’t always join its local fire departments and EMS agencies in mass-casualty incident (MCI) response training, but in Coral Springs it did. The decision to conduct interagency training made all the difference for the victims who were saved, which is why Cardona and Antevy advocate strongly for other departments to follow suit.
2. Train With Your Local Police
“There is no city in the country that has a stronger relationship with its police department than Coral Springs–Parkland,” says Antevy. “That relationship and training really came through for us that day,” despite breakdowns in communications between some of the responding agencies.
Following publication of the Hartford Consensus, which details the essential roles of bystanders and first responders in providing first aid at an MCI, the Coral Springs–Parkland Fire Department recognized the need to be prepared for the worst-case scenario.
“We as a department became aware of the importance of doing this training—getting the equipment, getting the supplies, putting the protocols in place, training all our fire department crews, and, most important, training with our police officers,” says Cardona.
This is a pursuit that can receive pushback from law enforcement personnel, who are trained to provide medical aid for themselves, not others, based on the nature of their work. Cardona says a large number of police officers and SWAT team members he knows across the country have not received bleeding control training.
The Coral Springs Police Department embraced this idea. With the help of Cardona, Chief Frank Babinec and the fire department’s in-house trauma expert, Capt. Justin Parrinello, in cooperation with the Coral Springs Police Department training officer, Carla Kmiotec, took the reins and developed an intensive interagency training program. From live-fire exercises to cadaver lab training, Coral Springs cops learned how to apply tourniquets and chest seals on both themselves and the victims they’ll likely be first to encounter (as was the case at the high school). Stop the Bleed Training has even been given to nearly all 900 city employees.
“That enabled better camaraderie when we were put into a situation like we were in Parkland… I think it all comes down to that relationship and the training,” says Antevy. “We had people in that building who went above and beyond and did the right thing to actually provide the care. I couldn’t be prouder of the fact that what was done by those law enforcement officers, SWAT medics, and fire department members is what saved all those lives.”
3. Forget the Triage Tags
“I always felt that with active-shooter victims, the priority is to very quickly triage them, and as you’re triaging them, you’re treating them with the appropriate lifesaving equipment, such as tourniquets, chest seals, hemostatic agents, etc.,” says Cardona. “From that point it’s about getting them loaded in the back of the rescue and en route to the hospital, while providing life-sustaining medical care en route.”
Victims were placed in the backs of golf carts, pickup trucks, and a BearCat at the school, just outside the building where they were found. They were then sent to the medical sector. Since bleeding control had already been applied inside the school, patients weren’t treated any further at the scene; instead, with no time to waste, they were placed onto waiting stretchers and loaded inside rescue trucks ready to depart for the hospital—an unusual but lifesaving decision Cardona made that day.
“These were almost all victims of large-caliber bullet wounds. All these patients needed to go to the hospital stat,” Cardona says. “These patients require a modified type of triage. In the time it takes to attach a triage tag to a patient, you can apply a tourniquet and prevent death by exsanguination. In the same number of seconds, you can restore the integrity of the chest wall of a patient with a bullet wound by applying a chest seal, and that person can breathe better. That’s what saves lives!”
With patients coming out of the building in waves, Cardona loaded one critical and one or two noncritical patients per ambulance in anticipation there would be many more victims. This expedited transport also made a significant difference in the patients’ survival rates by enabling treatment earlier at the hospitals.
Antevy supported Cardona’s move. “He made the right decision,” he says. “If he had decided to stop and wait and look and think, those people who had bullet wounds to the chest and so forth would have died—all of them.”
4. Good Relationships With Receiving Hospitals
Cardona says he knew having accurate records of patient counts and information in the event of an MCI would depend on the relationship between the receiving hospital and the EMS chief. While this may sound like a given, Cardona took this advice to the next level to ensure the most streamlined operations.
“One of the first things I did was call the emergency room medical director at the trauma center,” he says. “We’d established this rule with the doctors that if I called their cell phone, it’s important. And he answered on the first ring. He didn’t even know about the shooting when I called him.”
Cardona relayed the situation to the doctor. “I said, ‘I have a number of high-school-age patients who are victims of an active shooter. Are you ready to accept them?’ He said, ‘Yes.’ I said, ‘How many can you take?’ And I remember him telling me, ‘Send me what you got.’ And I said, ‘No, give me a number.’ And he said, ‘Ten to 15.’ I said, ‘Perfect, I’ll work with that.’ I hung up the phone. I started sending patients. I knew at that point he was ready to accept them.” Later into the call Cardona decided to start sending other patients to the second-nearest trauma center.
Their efficient exchange matched that of the record-keeping that was taken care of by the hospital EMS liaison.
5. Ensure an EMS Liaison Keeps Track of Patient Information
In the midst of a chaotic event such as the Parkland shooting, it’s no small task to ensure every patient is accounted for. That’s why it’s essential to have someone designated specifically to that duty.
All of Broward County’s hospitals have an EMS liaison, and the one on assignment at Broward Health North Medical Center was responsible for gathering information on all the patients.
“We needed to have some kind of information at the scene that could be cross-matched with the information at the hospital,” says Cardona. “I told my chief in charge of transport to keep track of unit number, patient, gender, and injury patterns. So we had that information for every patient we sent to the hospital, even though they didn’t have triage tags.
“I received a multitude of phone calls and text messages of support from all over the world during the time of the incident, but one of the most important calls came from EMS Division Chief Luis Villar from the neighboring Margate Fire Department. He said, ‘Juan, I know you probably have all the resources you need, but what can I do to help?’ I said, ‘If you’re in your office (which is closer to one of the receiving trauma centers), please report to the hospital and be my representative there for patient count and information sharing.’ This proved to be extremely valuable,” Cardona says.
6. Establish Mental Health Resources Before They’re Needed
“Even before the shooting, my department took a very active role locally and at the state level in two areas: cancer in the fire service and mental health/suicide prevention for firefighters,” Cardona says. “We had already started making great strides in those areas.”
Chris Bator, a captain at the Coral Springs–Parkland Fire Department, spearheaded the Fire and Safety Collaborative, which provides free resources to departments seeking to strengthen the physical and mental health of their employees.
“Instead of recreating the wheel at our agency, Capt. Bator helped put up all these resources, tool kits, and videos to help agencies who don’t have those resources readily available to them,” says Antevy.
Because these resources were already in place, they were ready to be activated the moment the shooting occurred, serving as a critical incident stress management tool.
“Not only during the incident but immediately after the call was demobilized, we started the formal postincident command process in terms of [providing] mental health and peer support,” says Cardona.
These resources will be available until February 14, 2019, and longer if needed, to give first responders the services they need (e.g., small group meetings and one-on-one sessions) to manage any symptoms of post-traumatic stress following the incident. These resources not only benefited those on scene (and even local responders who were at home agonizing over the difference they might have made had they been there) but also people who had responded to other tragedies like the Haiti earthquake and Pulse nightclub shooting and never had such assistance available.
“A lot of us are still very affected by all of this, including myself, [but] I feel embraced by this department,” says Antevy. “I’m really proud to say this department had all the right pieces in place long before this happened, without ever expecting we’d need them.
Antevy says having that emotional support already in place made a world of difference for responders’ mental wellness, “because if you don’t address it immediately, then that’s when the train heads off the tracks very quickly. Not to say that that’s not going to happen, but I would say it’s probably going to be averted in a major way.”
“Chief Babinec is determined to not allow this horrific incident have any type of major effect in the lives of our rescuers,” says Cardona. “Not as long as we can help prevent it!”
7. Engage in High-Fidelity Training
Antevy believes the standard of care for EMS providers needs to be heightened to keep up with the types of violence the nation is experiencing. Today departments that undergo Stop the Bleed training events typically receive a basic overview of how to use a tourniquet and pack a wound. This, Antevy says, is something civilians should learn. First responders, on the other hand, need to know how to apply these skills while facing an active threat.
“There’s nothing like being shot at or hearing bullets going off when you have a patient who’s bleeding, you’re in the middle of a hallway, and down that hallway may come a guy in one minute who’s going to kill you,” says Antevy. “Well, just knowing how to put a tourniquet on is not enough. You have to know, ‘Should I take this person and drag them into the classroom next door before I put the tourniquet on? Are the contents of the bag I have appropriate?’
“Training shouldn’t be watered down. My recommendation would be to use really high-fidelity-type training for our first responders—as if they’re in a war, essentially,” he says.
First responders in nearby Palm Beach County and some in Coral Springs–Parkland have partaken in high-fidelity training, where participants practice rigorous drills like learning how to provide medical care under live fire. The live-fire course is the brainchild of Don Deyo, an EMS lieutenant and retired Army Green Beret with 27 years of battlefield experience. “If we are going to provide care under fire, then first responders must practice in that exact type of scenario,” says Antevy. “Placing a tourniquet in a dark, smoke-filled room with shots being fired all around isn’t an easy task.”
It’s imperative for first responders to be one step ahead of the perpetrators of these acts of violence. The cost of preparation and training pales in comparison to the cost of potential lives lost.
The words of Evan Boyar, MD, medical director at Broward Health North Medical Center, summarize the significant impact the appropriate EMS decisions and actions played at this event:
“After a meticulous post hoc analysis of the victims transported to BHN, every patient was cared for to the highest standards in the prehospital setting,” Boyar concluded. “This ranged from swift on-scene evaluations to the appropriateness of tourniquets and application of bleeding dressings, adherence to Advance Trauma Life Support standards, concise and well-defined communications, expedited transport times, and rapid transition of care to our ED team. EMS personnel displayed courage and unprecedented professionalism throughout each step of the process despite the complex circumstances surrounding this tragedy. Every patient transported to our facility with potential survivable injuries walked out of the hospital. I strongly believe this is due to the heroic, seamless, outstanding care provided by EMS.”
Valerie Amato, EMT, is assistant editor with EMS World. Reach her at firstname.lastname@example.org.