Case Review: The Gravity of the Situation

Attack One responds to a report of a police standby. This call began with an unruly customer in a local bar and grill, and just as officers arrived, the man ran from the establishment and climbed up a 35-story crane at a building site next door. The police have asked for EMS assistance as they prepare for a standoff.

The Attack One crew receives a rapid briefing. The man is a murderer who escaped from custody in another state, stole a car and drove to this city. He entered the restaurant, where he ate a meal, drank a significant quantity of alcohol and then ran out to the adjacent construction site. That is the site of a future skyscraper, with about 15 floors already in steel and concrete. The crane serving the site has a horizontal arm about 200 feet above that, or about 350 feet off the ground. It is not being used at this time. The man climbed all the way up the vertical element of the crane, being chased by two police officers. Once at the top, he pulled up a segment of the ladder so he could not be reached directly.

After reaching the top, the man became very hostile, breaking off pieces of the crane and throwing them at the officers on the lower part of the ladder and persons on the busy street below. Unfortunately, when the crane operator had finished work the day before, he’d left the crane’s horizontal arm extended out over the street, allowing the man to drop or throw objects (now including his own waste) on the cars and pedestrians beneath. So the street was shut down, the special operations law enforcement team activated, and the crane left inoperable. As the law enforcement operation ramped up, EMS was called for the safety of law enforcement, bystanders and the hostile man.

The Attack One crew member in charge listens to the original briefing, meets the law enforcement senior officer in command, and notifies the on-duty fire chief to report to the scene. Within an hour, the lead members of the police department and fire-EMS at the site conduct an incident management meeting and start planning a prolonged operation. The man has been increasingly aggressive, moving around, breaking pieces and threatening officers and the crowd that has gathered below. His criminal record indicates he is dangerous, and his current behavior gives every indication he will not cooperate for any rapid resolution of the incident.

The initial incident management meeting results in creation of an incident action plan (IAP) based on a model developed and used daily by the fire-EMS agency. Originally in handwritten form, it outlines the initial critical elements of the incident. A Planning Section will be created and empowered to develop a detailed plan over the next 12 hours. In the meantime, the initial plan briefly outlines these elements:

Law enforcement is in charge of the operation, with an on-scene police major designated as Incident Commander. Leadership will change only if the man finds a way to access the crane operator’s booth and use the crane as a weapon or set it on fire—that would create a life-safety hazard, at which point the senior fire-EMS officer would temporarily take charge of the operation. Otherwise law enforcement is in charge of the operation and investigation, and will be assisted by federal law enforcement agents who have now arrived at the scene.

From the beginning, the major feels this will be a prolonged incident. Based on his experience with determined and desperate criminals in the past, he prepares his forces for an operation lasting three or more days. He suggests fire-EMS set up for a similar duration. He designates three important elements of the law enforcement operation, to rotate on a staggered basis. He will rotate his law enforcement command staff and PIO in 12-hour shifts; his highly trained SWAT members, who will be up on the crane, in 8-hour shifts; and regular uniformed officers on normal 6-hour shifts to provide perimeter control. Investigation staff will be kept on call and summoned only if the incident appears to be coming to resolution.

The Planning Section is asked to address contingencies: What is worst that could happen? What will improve or worsen the situation? What can be done to prevent anything worse or precipitate a crisis, like the man jumping off the crane? The Finance Section will develop a budget for all elements of the operation.

The media presence increases rapidly, especially with the man yelling obscenities and throwing objects at the crowd below. The Joint Information Center is set up, with the law enforcement PIO as its lead.

Incident management meetings will be conducted every two hours until 6 p.m., then every four hours. As rotating crews are brought to the scene, they will be briefed at the next meeting. Any updates to the operational plan will be shared at those meetings, unless a crisis meeting is required due to a rapidly changing condition. Each discipline present needs to assign a member to the Planning Section, so that plans can encompass everyone’s needs. The first Planning Section meeting will be held in one hour.

EMS personnel are responsible for the Medical Branch. Fire-EMS members are to prepare for injuries or illness for all groups present, and have a precise operational plan as the incident comes to resolution, as the media will be recording every detail. The Medical Branch will develop a plan for all possible medical events, and prepare local hospitals. The plan will include contingencies for injured police officers and the perpetrator, including trauma management of someone falling or jumping off the crane. It also will include management elements for care of the perpetrator should he be sedated or injured in an altercation on the top of the crane. It needs to be precise as to what will happen if police need the perpetrator restrained: Who is in charge of that patient at that time? What if he is very ill or injured? Where will he be transported if he is ill, injured or burned?

High-angle rescue crews are brought to the scene, and a joint fire-EMS operational plan is established.

Over the next four days, the man stays on the crane, establishing places to sleep, shield himself from the sun, scream at the crowd below, and have short and hostile conversations with negotiators. He has no food, and the only water he ingests is from some brief rain showers on otherwise warm and sunny days. The busy street below remains closed down.

Over time, the man’s behavior generates international media interest, and various plans are considered to end the standoff. At times he threatens to jump. This generates a firm plan by law enforcement that they will do nothing to prompt irrational behavior or incite him to do anything dangerous.

The technical rescue crews and selected law enforcement personnel who can tolerate working at high altitude establish a “rescuer” area on the upper surface of the crane, and bring supplies up a little at a time (by hand) that will be used to bring the man down safely. The man’s strongest drive is his thirst, and law enforcement uses that in an attempt to get him to surrender. They display large bottles of water, drink some of it in front of him and ask him repeatedly to step toward them to get some of it. They devise a safety restraint system so the man can be immobilized, secured and lowered to the ground once in custody.

On the fifth day, the team knows the operation is coming to a resolution. The lack of water begins to affect the man, and he becomes less hostile and more willing to discuss the bottles of water on display with the police officers. Medical Branch physicians are fairly sure dehydration will be the most influential medical issue, and that restraints will have to be physical, for fear that any chemical restraints or sedation could be unpredictable and dangerous.

On the evening of the fifth day, all plans to bring the man off the crane are finalized. The Attack One crew is serving on top of the crane. The suspect becomes more agitated, and police negotiators believe he can be tempted to come to the middle of the crane platform by placing more bottles of water there. When the man comes to get them, they can safely secure him using an electronic stun gun on a platform area where he can’t fall. The operation is successful: The barbs hit the man in the legs and immobilize him, and he is secured in handcuffs.

The Attack One crew does a rapid medical assessment while the technical rescue crews set up to secure the man in a basket, to be lowered by hand and pulleys. This will take 20 to 25 minutes. The man has damaged the crane so much that it can’t be used to lower him, or the public safety personnel and their equipment, to the ground.

The man, handcuffed and restrained, is given a small amount of water by mouth and a primary EMS assessment. He is sunburned, dehydrated, tachycardic and still uncooperative. The barbs are removed from his legs without causing significant injury. It will not be safe to start an intravenous line on him when he will need to be lowered by rope, by himself, over the long distance. That will be left to EMS crews on the ground.

The man is secured firmly in the basket, given a couple mouthfuls of water to make him more comfortable, and then the technical rescue crew initiates the lowering process.

Once he’s down, the waiting EMS crew on the ground then carries out its elements of the plan. They remove the man from the basket; law enforcement personnel read him his rights, then handcuff and secure him on an ambulance stretcher. EMS personnel recheck his vitals, start an IV line and give him a modest bolus of saline. The man is not nauseated, so he drinks some electrolyte solution offered to him. The EMS cot is placed in a secured ambulance, and two police officers accompany the crew to a predetermined hospital, where ED staff has been notified the man will be taken.

A complete EMS team remains at the scene to ensure safe coverage as remaining personnel and supplies are brought down off the crane. Command staff completes a debriefing and incident wind-down, and the area is left secure for investigators to complete their work the next morning.

Hospital Course

The patient is stable on arrival in the ED. He is provided rehydration with electrolyte solution and calories through a carbohydrate-rich snack. He has no abnormalities of electrolytes. He is discharged to jail with instructions for a gradual return to a balanced diet.

Case Discussion

EMS functions will be unique when working in different incidents within the public safety arena. What are implications of working with law enforcement in incidents where they are directing the operation? In many of their incidents, there is no patient on EMS arrival, but a potential for one or many patients, including law enforcement personnel. On arrival at such a scene, it will be important to determine who is in charge of the incident. At some point, an incident requiring significant time and dedication of resources will necessitate implementation of an incident management system. Prolonged incidents will necessitate development of an incident action plan. This will crystallize the responsibilities of leadership and set a path of cooperation for safety and effectiveness.

Important issues to be addressed in a prolonged law enforcement standoff include: Who is in charge of which elements of the operation? What would cause leadership to change? If something is suddenly blown up or catches fire, or there are multiple critical injuries, who will make critical life safety decisions? How will management occur over time? Some operations extend over multiple days or even weeks. Will leadership pass from law enforcement to fire officer and then back to law enforcement, depending on priorities?

How will the Planning Section address contingencies? What’s the worst that could happen? What will be done about it? What will improve or worsen the situation? What can be done to prevent anything worse or that might precipitate a crisis? What impact could medical events have on the situation? Who can make decisions if police officers request advice? What if they ask if the perpetrator can be sedated or paralyzed using medication?

At some point a standoff will be resolved, preferably through peaceful means with no casualties. What are the medical treatment priorities then? What will happen when the police need the perpetrator restrained? Who is in charge of that patient at that time? What if he is very ill or injured? Where will he be transported? When and how will incident management meetings be conducted? How can rotating crews be briefed and carry forward operational plans? Since the operation may come to a crisis at any time, on any shift, it is critical that each group of fire-EMS providers assigned to the scene get a precise and detailed briefing.

Media presence is a planned element of these operations. Joint Information Center operations are mandatory, and it is likely that the law enforcement PIO will be the lead. Fire-EMS members working the scene need to be prepared for precise operations as the incident comes to resolution, as the media will be recording every detail.

In prolonged incidents, all disciplines will need to rotate crews. This includes chief officers, technical rescue leaders, safety officers and PIOs. There is a clear need for consistency of planning and communications, and the potential that crews will need to be rotated on unusual shift schedules to reduce the impact of the incident on ongoing routine operations, and to allow a smaller cadre of members to be familiar with its details. For example, in this incident members of the Command staff and the high-angle rescue crews could be rotated on a 12-hours-on/12-hours-off schedule, involving overtime coverage, to remain fresh and prepared for the operations taking place high up on the crane. Crew members responsible for the most complex operations are likely to be rotated in such a manner.

Prior arrangements for these unusual events should be made with the local trauma center and with any hospitals that usually accept jail prisoners or burn patients. If there are lengthy transport times following an incident in a rural setting, plan with local air ambulance crews far ahead of time what they can do to transport non-dangerous patients. Most air ambulance services are not prepared to manage potentially dangerous persons in police custody.

James J. Augustine, MD, FACEP, is medical advisor for the Washington Township Fire Department in the Dayton, OH, area. He is director of clinical operations at EMP Management in Canton, OH, and a clinical associate professor in the Department of Emergency Medicine at Wright State University in Dayton. He is also a member of the EMS World editorial advisory board. Contact him at jaugustine@emp.com.