Schools, churches, nightclubs, movie theaters, music venues, shopping centers, office buildings, federal properties and streets—all of these have been the scenes of active shooter/hostile events (ASHEs). These incidents may vary in location, but their goal is the same: An individual or group sets out to cause as much harm as possible.
Today every location, no matter how sacred or unexpected, is a potential war zone, and nobody is immune, not even EMS. Consequently our children, siblings, parents, colleagues or friends could be the next victims. Although it is not always possible to prevent ASHEs or protect victims from harm, EMS has the tools and skill set to influence the outcomes of situations by giving victims a fighting chance at life.
"We are, after all, the front line of responders and highly skilled clinical professionals," says Ed Racht, MD, chief medical officer at American Medical Response (AMR). "It is our responsibility to bring order to chaos, however challenging it might seem."
While there is no one definitive answer or approach to combating ASHEs, Racht and his colleagues at AMR, a division of Envision Healthcare, believe in implementing an evidence-based approach that evaluates and applies industry research and lessons learned from previous incidents.
With years of field clinical expertise and experience serving their communities, Racht and a pair of veteran AMR leaders—Dave Molloy, operations manager in Redlands, Calif., and a responder to the 2015 Inland Regional Center shooting in San Bernardino, Calif., and Scott Newlin, Jr., EMS supervisor and coleader of special operations in Concord, Calif.—share some of the lessons learned and their thoughts on how to address ASHEs.
It was 11 a.m. on a Wednesday when Molloy received a call from his field supervisor asking for help responding to a scene with 20 gunshot victims. Within minutes he deployed with crew members and five ambulances. "Then a call came in for 10 more ambulances," Molloy recalls, "and that's when I knew the situation was dire. Upon arriving at the scene, the first thing I saw was a helicopter taking off from the nearby golf course and the bodies of victims on the ground next to a fire engine."
At that moment Molloy faced a common dilemma: having to begin operating without knowing the full dimensions of the attack, which involved two perpetrators and ultimately left 14 dead and 22 wounded.
Active-shooter situations and other hostile events can take on many forms. Whether it is an individual charging a truck through a crowded French street on Bastille Day, a lone perpetrator mowing down revelers at an Orlando nightclub or a well-planned attack on an office training session as in San Bernardino, these hostile and mass-casualty incidents (MCIs) generate fear, bewilderment and disorder.
U.S. government agencies, including the FBI, define an active shooter situation as "an individual actively engaged in killing or attempting to kill people in a confined and populated area" with firearms. Furthermore, "Unlike a defined crime, such as a murder or mass killing, the active aspect inherently implies that both law enforcement personnel and citizens have the potential to affect the outcome of the event based upon their responses."
According to the FBI, there were 20 active-shooter incidents in both 2014 and 2015. In total they left 92 dead and 139 wounded. In a previous FBI report, A Study of Active Shooter Incidents in the United States Between 2000 and 2013, there were 160 active-shooter events during which 486 people died and 557 were wounded. The 13-year study revealed an average of 11.4 active-shooter events a year, with numbers more than doubling after the first seven years.
Of those 160 events, approximately 66.9% ended before law enforcement arrived. Although data reveals incidents can be over in as little as 2–3 minutes, there are several complications and uncertainties that can prolong the appropriate medical treatment of victims. For example, improvised explosive devices (IEDs) or multiple perpetrators could be present, as was the case in San Bernardino and with the 1999 Columbine High School attack in Littleton, Colo.
"I remember we were all horrified when the shooting at Columbine happened, but most of us in EMS thought it was an isolated event," Racht says, comparing the progression of incidents to an emerging disease. "The rapidly evolving and complex circumstances require us to continually adjust our practices to ensure the safety of responders and civilians while also maximizing the survivability of victims."
AMR's ASHE Initiative
As the largest EMS provider in the nation, AMR wants to make sure its crews and community members are prepared to respond and know how to react to the constant threat of ASHEs. Thus AMR has established a dedicated task force consisting of leading EMS professionals and physicians who are assessing the current state of the art and science of managing these events from operational and clinical standpoints.
In the past two years, AMR was on scene for the San Bernardino attack, the Planned Parenthood shooting in Colorado Springs, Colo., and the Pulse nightclub shooting in Orlando. "In response to these incidents, we worked with our public safety colleagues and receiving emergency physicians. We are now using that experience to gain a better understanding of how to train, prepare and respond to events," Racht says.
During this process, he explained the group continually addresses operational challenges regarding the responsibilities of EMS, best staging practices, the use of personal protective equipment, the implementation and integration of tactical medicine programs, the coordination of multiple first responder disciplines, the role of civilians and the critical importance of hemorrhage control.
Role of EMS and Other First Responders
Regardless of the community or level of the responder, the role of EMS in ASHEs is the same: Focus on the safety, stabilization and transport of patients. "The levels of care provision then change, aligning more with basic lifesaving interventions to accommodate the situation, the number of patients and the combat-type injuries patients sustain," Newlin says.
Racht, Molloy and Newlin agree there has to be a cultural shift in the way first responders treat ASHEs. "We can't operate as single entities," Newlin notes, expressing his desire to see an industrywide emphasis on integrated training.
Almost all hostile events and MCIs require the resources of multiple responder disciplines, including law enforcement, fire, EMS and emergency physicians, among others. "We have learned the most effective response to ASHEs is through a synchronized, aligned, interprofessional approach," Racht adds.
Newlin facilitates some of his operation's training practices with his partner. He has also worked with 10 of the 20 law enforcement agencies in his county on ASHE preparedness. In total he has participated in about 25 different active-shooter drills.
In addition to extensive training through AMR, Molloy says the exercises he participated in with local law enforcement and fire agencies helped prepare him for San Bernardino. They helped the responding parties work well at the scene.
Afterward he said agency leaders discussed how they could handle future situations. They concluded that a best practice would be to have the primary operating unit on scene take the lead. The next-closest operating unit would then establish a local company emergency operations center and take care of off-scene logistics.
Another change Molloy would like to see is a designated dispatcher for major events. In 2015 the San Bernardino dispatcher was handling both the attack and unrelated 9-1-1 calls, which became complicated.
According to Racht, a significant component of an integrated strategy is preparing law enforcement and other responders for aggressive hemorrhage control. "If law enforcement—which has the training and expertise to go deeper into the uncontrolled hot zone—can rapidly identify and control significant bleeding and bring patients to safety," he explains, "they can have a significant impact on patient outcome and loss of life. As a result care begins earlier, and the problems are addressed before they become irreversible."
That knowledge would have been beneficial in the 2012 Aurora, Colo., movie theater shooting when EMS struggled to reach patients and many of the responding police did not have skill sets beyond basic first aid to treat them. Out of desperation, officers transported patients to nearby care facilities. While their actions helped save lives, they could have employed hemorrhage-control techniques at the scene.
"Given the often chaotic and urgent nature of such events," Newlin adds, "the traditional responsibilities of agencies often intertwine." However, he underscores the need to develop a well-defined plan and clear communication with receiving facilities. "Some hospitals are not trauma-receiving facilities, while others might not have the resources to handle high volumes of trauma patients. We have to know which is the most appropriate for patients' required level of care."
"Within 15 minutes of being on scene, police rushed toward me, saying they didn't know the whereabouts of the shooters," Molloy says, recalling how his attention immediately shifted to the safety of everyone. Then law enforcement told them they found explosive devices. "You gotta be kidding me," Molloy uttered in disbelief. As the first-responding agency, the fire department established the triage area, but many of the responders unintentionally and suddenly found themselves in the hot zone (a situation AMR has deemed "suddenly hot"). Fortunately the crews had already gathered the patients who needed transportation and were able to quickly evacuate and set up at a fire station less than a mile away.
Despite zoning confusion, Molloy says he found the "chevron staging" of vehicles advantageous. "It allowed us to fit more units in a small space and get patients out of there as quickly as necessary," he says.
Naturally the hot zone poses the greatest risk and is not an area of operation for traditional EMS. While Molloy and his crew were fortunate nothing happened, their experience demonstrates the unpredictable nature of ASHEs. If EMTs and paramedics suddenly find themselves in the hot zone, their safety becomes the absolute top priority.
"Situational awareness is vital," Newlin says, stressing the potential of a secondary attack. "In some instances first responders have been a secondary target—as seen in the 1997 women's health facility bombing in Atlanta," which left several EMS, fire and law enforcement personnel wounded.
The cold zone is, in theory, the safest and the most effective place for EMS to operate. The warm zone, while clear, is not secure. As part of a rescue task force, Newlin has the equipment and training to treat and evacuate patients in this area with the assistance of law enforcement. In this zone, care is restricted to basic lifesaving techniques such as hemorrhage control and airway management.
The appropriate staging strategy is an ongoing debate that requires research and careful assessment. Newlin and Molloy firmly believe all first responders should have advanced training, so they are prepared and comfortable enough to operate in a high-risk and dynamic environment even if they do not enter the warm zone.
Early Hemorrhage Control
In most ASHEs patients present with gunshot wounds, shrapnel injuries, face and neck trauma, soft tissue injuries and airway restrictions. One of the biggest concerns is hemorrhage, and more often than not patients' injuries require surgery. The nature of ASHEs does not always permit rapid treatment and extraction, and as a result victims often die from exsanguination and resulting complications before receiving definitive care. "In EMS, time is blood," Newlin says.
"Past events have taught us that the greatest opportunity for lifesaving intervention is early," Racht says. Military studies have shown that hemorrhage is the leading cause of preventable death in patients with significant trauma. To the extent life-threatening injuries in ASHEs reflect those in combat, "we know tourniquets and aggressive hemorrhage control will help stop bleeding. Mere minutes can make a significant difference in a patient's outcome."
The term first responder does not always refer to police, fire or EMS. The very first responders in hostile situations are most often bystanders. Part of AMR's initiative is to "show civilians that, despite the tumultuous nature of hostile situations, they have the ability to provide basic lifesaving support," Racht says.
There are good analogies in EMS history. Generally the public is aware of compression-only CPR and basic first aid, but not as aware of hemorrhage control. According to Racht, the Stop the Bleed campaign is an invaluable public education tool. The nationwide campaign makes hemorrhage control approaches easily applicable in public areas and promotes the idea that bystanders can help.
They say additional public education should include the "run, hide, fight" mentality. The saying, which is simple and easy to follow in fast-paced, chaotic incidents, incites movement in those who might otherwise freeze—mentally and physically—out of fear. "We want to encourage people to move and escape if possible," Newlin says. As a last resort they should prepare to startle and disarm the perpetrator by attacking with whatever tools are available. In an office building or school, that might be a chair or fire extinguisher.
One aspect Molloy says deserves more attention is the emotional impact of ASHEs. Even with 22 years in the industry, he found San Bernardino a lot to process. "At one point I was surveying the scene, making sure our folks were taking care of the task at hand," he says. "Then I quickly had to move everyone to safety. I was also trying to console colleagues who were concerned about their safety and the possibility of subsequent attacks."
Molloy prides himself on remaining level-headed and focused on the job but says the situation was difficult. Later that day he learned one family friend died and another was injured. "That day certainly altered my view on life," he admits.
"ASHEs have permeated our local, national and international communities," Racht says. "Now, as we have done with epidemics like Ebola and AIDS/HIV, we must confront the 'disease' vigorously by training ourselves and the public to react in a very deliberate and controlled manner."
As experienced responders, the three know it is imperative to establish a meticulously coordinated approach that includes the communication and training of multiple clinical and law enforcement disciplines. "Furthermore, we have to emphasize the important role of civilians. They, too, are first responders and crucial to improving the survival of patients," Racht says.
"We are all in this together, and this is a powerful message to everyone involved about the importance of working together and sharing the good, the bad and the ugly in order to be prepared for the next one."
Ultimately, through extensive training and the constant evaluation of previous cases, its leaders believe AMR will be able to effectively prepare for and respond during and after moments of crisis. "Our communities expect nothing less," says Racht.
Dave Molloy is a paramedic and the operations supervisor for AMR Redlands. He has more than 20 years of experience in EMS and currently serves as an adjunct faculty member and EMT program instructor at Crafton Hills College. He received his bachelor's in business management from the University of Redlands.
Scott Newlin, Jr., is a paramedic and EMS supervisor for AMR Contra Costa. He has more than 13 years of EMS experience, 12 of which have been with AMR. He also serves as the coleader of special operations and supports his operation's training and rescue task force initiatives.
Ed Racht, MD, is the chief medical officer at AMR and a renowned speaker in the EMS community. He has more than 20 years of experience in EMS and healthcare systems. Racht received his undergraduate and medical degrees from Emory University and completed his residency at the Medical College of Virginia.