Every month in Lake County, Ohio, we receive continuing education from our medical control. One of those recent training events concerned active shooters.
I have an extensive tactical and medical background that includes 20 years in the army, three combat deployments, being a TEMS operator on our county SWAT team, and 25 years as a paramedic. The active-shooter training we were getting made no sense to me, and I made that clear. Shortly thereafter our executive captain asked me to coordinate with the police department and devise a local response plan for active shooters.
We conducted wide research into how other departments respond to active-shooter incidents. We found their responses resembled a typical mass-casualty response but with body armor. Their commanders generally assumed a conventional approach to unconventional incidents, and the concept of operations could sometimes be lost. Their approaches emphasized command structure and scene safety, while victims lay bleeding on the ground. We chose a different and bolder approach.
Our city of Painesville is the county seat but has only one fire station, the busiest in the county. We operate with a minimum six-person shift, with more than 4,000 calls yearly. Because of this call rate, we believe more in load-and-go than stay-and-play. Our active-shooter approach is in line with that mentality. Our police department wants EMS on scene and in the building as soon as humanly practical, and we’ve been happy to oblige.
In the past and in other locations, law enforcement had been reluctant to allow EMS entry for fear of introducing more potential victims into the situation. Our PD said as soon as the shooter is contained, they will have EMS enter. Notice I said contained and not apprehended.
The next hurdle to this new approach was command and control. Law enforcement does not use the Incident Command System like the fire side, so that required my executive captain to bring them up to speed on the ICS and encourage the police officer in charge to approach our fire command to see how we use it.
Now that the 30,000-foot view was taking shape, we needed to address the tactical command. We visited several other departments and observed or participated in their active-shooter exercises. We found there was a lot of confusion and freelancing.
We recognized we had to control the entrance. That’s when we developed the “traffic cop” and operations positions. The traffic cop is a police representative who’s stationed just inside the point of entry into the building. Operations is a fire representative who stands right next to the traffic cop. They are essentially our “bouncers.” No one goes in without their approval, which solves the problem of tactical command and control. We decided our interior teams were going to be assessment and extraction teams, each consisting of two police officers and two EMS providers.
The New Process
Now that we had a plan, we ran exercises to test our concept. After about 100 iterations we tweaked our performance to where we were able to assess and extract 15 victims in less than 10 minutes (under varying scenarios).
The PD makes entry, looking for the shooter. While that occurs the FD arrives. The PD announces which door will be used, and FD personnel dismount and head toward the door, stopping outside or taking appropriate cover nearby.
The FD officer in charge establishes command and helps construct the assessment and extraction teams. The first incoming officer takes over establishing more extraction teams. The next-ranking FD will be the operations position and will head into the building with the traffic cop. All interior teams will flip to radio frequency 1A, which is reserved for them and the operations person.
When PD says it is clear for FD, operations calls the first assessment team in. A good rule of thumb we’ve found is one assessment team per floor, unless there’s a very large and divided area involved. When the assessment team contacts the first victim, one EMS provider will initiate assessment and treatment while the other radios their location to the operations person and makes a note of the location to keep with the team. Before the team leaves the building, operations and the assessment teams reconcile their victim lists to ensure everyone is accounted for.
Our assessment and treatment plan is easy: First, if a patient is not alive, we place an X on their forehead and move on. If they are alive, what is their injury? The only treatable injuries are arterial bleeding, massive abdominal injury such as evisceration of the intestines, and sucking chest wounds. The whole concept of the operation is to get as many viable victims, regardless of injury, out of the building as possible. More definitive care and a proper triage can be performed at the casualty collection point.
As soon as the operations person gets word of a victim, an extraction team is assigned and sent to that location. We’ve found that running six extraction teams works well for us. We have teams going in and out at the same time, maximizing the effort.
Our command vehicle has floor plans of most large local buildings; these are given to the operations person to help direct the teams. The role of the traffic cop is to help direct police activities and advise the operations person of any changes in the situation.
Viable Victim Extraction
The main concept of operations is viable victim extraction. Given the dynamic environment, teams can operate at their discretion based on whatever situation they face.
There are far too many variables to plan for, so trust in your teams is imperative. Below is a breakdown of the various positions with their roles and responsibilities.
Respond to scene, identify appropriate point of entry;
Establish operations interior position;
Establish appropriate staging area for assessment and extraction teams, including equipment;
Establish and ensure all assessment and extraction teams are on radio frequency 1A;
Check to ensure all equipment is present and operational;
Start to establish both assessment and extraction teams;
Monitor situation and stand by for entry.
Operations will be determined by the FD OIC or situation at hand. This will be the first FD person in the building;
Make contact with the traffic cop and receive an update of the situation;
Traffic cop will notify operations when it is clear to deploy the assessment team;
Operations will call in the assessment and extraction teams as needed and direct them appropriately;
Operations will ensure all team members are on the proper radio frequency prior to deploying them;
Operations will keep a list of victim and DOA locations to be given to command. No extraction team will be sent to recover a DOA.
Ensure both members of the team have treatment vests on;
Upon entry the assessment team will be given the appropriate direction;
Move in a linear formation, with one LEO in front, followed by two EMS personnel, ending with one LEO in the rear;
Front FD will direct the formation when to stop at a victim and when to bypass a body;
When assessing a victim, front EMS provider will perform a rapid assessment of 10–15 seconds and treat only major bleeding, gaping injuries, and sucking chest wounds;
The second provider will relay victim locations to operations for extraction. DOAs will not be extracted but will be called in to operations. If an assessment team comes across any walking wounded, it will direct them shelter in place and notify operations so an extraction team can retrieve them. We do not want walking wounded wandering the halls! A written record of victim and DOA locations will be kept and compared with the list given operations prior to leaving the building;
For DOAs: If an injury is obviously incompatible with life, keep moving past the body and call in the location to operations. If a victim is DOA upon assessment, mark an X on their forehead and call in the location;
Identify when the first EMS provider is running out of supplies, then switch positions with the second.
Ensure one member of the team has a treatment vest on;
Upon entry, coordinate with operations to learn the victim’s location;
Repeat location to operations to ensure proper location;
Move in a linear formation, just as the assessment team does;
If, en route to a victim, the team comes across a viable victim who does not seem to have been treated, treat the victim and call in the location to operations, then proceed to the original victim, and operations will assign another extraction team for the new victim. We do not want to start skipping victims, as we may overlook one;
Upon arrival at victim, ensure viability. If still viable, place the victim on your extraction device (we use Graham MegaMovers). Extract the victim as expeditiously and efficiently as possible. If the victim is no longer viable, notify operations and stand by for another assignment;
Take the extracted victim to the team’s original point of entry and hand them off to a representative at the casualty collection point, then stand by for another assignment.
What makes this system work so well is our ability to gain entry more quickly and thus initiate life-saving measures earlier, ensuring a better chance of survival. Our two “bouncers” at the door are the key to avoiding chaos and freelancing, plus add better accountability of victims and DOAs. Probably one of the best takeaways is the unifying of police and fire through a unified vocabulary.
The fire service is big on choreographing incident responses. But as we used to say in the army, situation dictates—so there is no perceived plan to change but only a concept of operations to guide you.
This is an unconventional mind-set and may be difficult to wrap your head around, but having a conventional mind-set in an unconventional situation will only hurt your chances of maximizing a successful outcome.
Robert Hendershot, EMT-P, is a firefighter-paramedic for the city of Painesville, Ohio.