EMS Response to Mass Violence

   Virginia Tech in 2007. Mumbai in 2008. Fort Hood in 2009. As mass-shooting incidents continue, it is important that responders are aware of their dangers and response considerations. Wherever you work, you and your agency will likely face the challenge of responding to a critical mass-shooting or mass-violence event.

   These can occur in urban, suburban and rural settings, and can include mass shooters/active shooters, bombings and even mass stabbings. Targets may include responders as well as civilians. Some responders may face this kind of violence on a smaller scale every day; for others it may be a less-frequent occurrence. But for all, it's something to be prepared for.

   In 2006 the Department of Homeland Security released an information assessment advising that domestic and international terrorist incidents may expose first responders to significant life-safety risks, and that first responders may be the actual targets of attacks or ambushes. Lack of a properly coordinated and planned response can lead to confusion, bad publicity and even death and injury to responders and the public.

SIZE-UP AND COMMAND

   Upon arrival at any mass-violence incident, it is important to conduct a quick "windshield survey," even when a scene is believed to be secure. It is always important to gain as much prearrival information as possible and listen for key indicators such as victim locations, numbers and types. If possible, scan the area using binoculars, spotting scopes or vehicle-mounted cameras before approaching.

   For fire/EMS agencies, typical procedures require that law enforcement be dispatched to any type of incident with a potential for violence, but you may find yourself on such a scene due to a wrong address, victims coming to you or just a sudden discovery or eruption. Never hesitate to call for law enforcement assistance if you even think you may need it. Any type of mass-violence incident should raise a red flag for all responders to be maximally aware of what is occurring prior to and during their response.

   The Incident Command System (ICS) is one of the best tools for agencies to utilize when responding to these types of incidents. During the initial size-up, there are some actions the Incident Commander will need to take, including notifying dispatch of the command post location and assessing the situation as best as possible by quickly gathering information from witnesses and other responders. On-scene responders will also need to direct arriving units and designate at least one staging area, perhaps more. Immediately request partner-agency representatives to come to the command post to start building unified command. It would be counterproductive to have multiple incident command posts. Staging, command, triage and treatment areas may have to be up to a mile away from the scene, due to the distance a round fired from a weapon can travel.

   To maintain situational awareness, command staff should monitor radio traffic and other communications for other, similar situations or incidents. Consider the need for additional personnel and resources in case of secondary shooters or attacks. If an incident area is large, such as a college or mall, divide it into branches or divisions to make the scene more manageable. Your plans and guidelines should be flexible enough to address the changing situation and additional threats.

OPERATIONS

   When possible, EMS and fire units should remain in the staging area until the scene is secured by law enforcement. Responders may initially run into victims fleeing the incident. Work to gather information from these individuals, and direct them to safe areas using verbal commands or PA systems. Clear communications are necessary for effective operations.

   These situations could also become hostage events. These events may occur during business/school hours, and during these types of incidents, young students and victims may not understand instructions. They may even hide from responders. Notify all key supporting entities (emergency management, hospitals, mutual aid agencies, etc.) as soon as possible. Plan on large and immediate responses to the scene from media and parents, family and friends. EMS and fire personnel should wear helmets and clearly marked apparel. If available, obtain body armor for those responding into the impact area. Depending on the number of resources responding, multiple staging areas can help expand your span of control. Consider assigning someone as an observer or "lookout" to watch the enter scene from a secure vantage point for any additional threats or considerations. Observe windows for signs of attackers and victims.

   Responders may have friends or family among the threatened, wounded or dead, which can have an emotional impact on their performance. During these types of events, 9–1-1 call volume may go up (related and unrelated), so communications centers may need to rapidly bring in extra staff and establish extra phone lines.

   Activate your local EOC as soon as possible for long-term multiagency response, recovery, investigative and support efforts. Establish a joint information center (JIC) involving all key agencies and players to manage media efforts. Consider family assistance centers (FACs) near the site and in other locations. Consider CISM for all responders.

   Fire/EMS should only enter a scene if it is confirmed that all suspects are confined or neutralized. Even then, only a small number of personnel should enter. Law enforcement officers should ensure their safe passage.

   Deploy trained and equipped tactical medical personnel to assist in rapid deployment and downed-person rescues in the hot zone. EMS may need to utilize a "scoop and run" approach from the immediate incident scene. Absent an ongoing threat, healthy civilians can help evacuate the walking wounded and provide basic first aid to the injured.

   EMS may need to implement disaster procedures such as triage, triage tags, casualty collection points (CCPs) and field treatment areas for minor injuries. Implement local mass-casualty/mass-fatality procedures. Quickly remove victims and render aid in a secure location. Conduct triage outside the hazard area. Helicopter landing zones for medical evacuations may need to be established. Use litters, blankets, SKEDs or backboards. Triage will be conducted at least twice, once at the scene and again at the hospital. You may have to search beyond the immediate scene for victims who fled or were not able to call for help.

TACTICAL MEDICINE

   One excellent source for protecting your responders and the public during a mass-violence response is the use of tactical medics. According to the International Tactical EMS Association (ITEMS), tactical providers can "maintain the wellness of the team's members and provide immediate medical care to anyone in need, whether they're law enforcement officers, innocent bystanders or suspects." Agencies should look at self-aid, buddy-aid, "officer down" and tactical medic courses for dealing with these types of situations. These medics receive training in subjects such as firearms safety, remote-site medical care, terrorism, preventive medicine, tactics, ballistic injuries, extraction, etc. Tactical medics are great assets to any agency during a mass-violence response.

CONCLUSION

   Safety is paramount for all responders during these types of events. Remember to follow your local guidelines and procedures. The more our public safety agencies prepare, the better they'll be able to respond to and effectively manage any type of situation that might arise.

EMS Body Armor

   Already part of the law enforcement ensemble, body armor can be an essential component of EMS responders' PPE, especially in a mass-violence incident. However, the cost can be restrictive, with armor typically starting around $400-$800 per unit. That's why some agencies provide it only to units that routinely respond to large numbers of shootings, stabbings and other violent incidents.

   If your agency is looking into purchasing armor, do careful research, as there are numerous types and levels. "Hand-me-down" armor/ballistic protection from the military or law enforcement may not be the best choice, as its protective abilities may be damaged or worn out, and using it could open your agency up to legal liability if something goes wrong. —AV

   August Vernon is assistant coordinator/operations officer for the Forsyth County (NC) Office of Emergency Management. He teaches courses in mass-violence/mass-shooting planning and response, and incident and emergency management.