EMS Response to Mass Shootings

     There have been a number of high-profile mass shootings in recent years, and in each incident, EMS providers treated and transported victims in an orderly and systematic fashion. But such smooth responses can't be taken for granted. In responding to mass-shooting incidents, initial arriving crews are faced with horrific scenes that test even the most seasoned medics. Those first-in crews set the stage for the entire incident. This is where solid training and practice pay off.

     It all starts with the mass-casualty drill most EMS communities hold once a year. These drills usually consist of numerous simulated victims surrounding a crashed bus or airplane, or a model of some other disaster that could happen in the community. Occasionally these drills do nothing more than get people excited and produce nothing beyond a report saying the drill was successful. But how can you honestly evaluate the capabilities of a rescue community unless its services are really put to the test?

     Say your community is holding its annual mass-casualty drill next week and notifies all participating emergency services of the exact time and date. The drill depicts 20 high school students in a simulated bus accident. The students are strewn around and in a bus that has rolled over and crashed into a tree.

     The call goes out, and the first unit to arrive is Medic 1, with an EMT and paramedic on board. The paramedic does a quick sizeup and calls for more help. You know you're going to need 20 c-collars, 20 backboards and numerous straps to package these patients for transport. Did you actually have the c-collars, backboards and straps on the scene, or were they simply simulated? What about bandages, splints and IV supplies? Granted, you may not have used this equipment during the drill, but was it readily available and transported? How will you transport all these patients? Are you planning on using air assets? What if the weather is stormy and helicopters aren't flying?

     Chief Russell Lanson of the DeKalb (IL) Fire Department believes in what he calls the PPP (practice, preparation and partnership) principle. When his department responded to Northern Illinois University last Feb. 14 in response to a shooting that killed five and injured at least 15, his principle was severely tested. But having been practiced--most recently during a mass-casualty drill three weeks earlier--it fared beautifully. "I wouldn't change a thing" about the NIU response, Lanson says.

     How you practice is going to define how you handle the real thing.

INITIAL RESPONSE
     Perhaps unaware a mass shooting has taken place, a first-on-scene crew may be overwhelmed by the chaos, confusion and sheer number of victims. Their initial actions will directly affect the outcome of the operation. Although the first desire is always to provide treatment, command must be assumed first, before trying to make order from the mayhem.

     Early on the morning of April 16, 2007, the Virginia Tech Rescue Squad's VTRS3 was dispatched to West Ambler Johnston Hall on the Virginia Tech campus in Blacksburg for a report of a person falling out of a loft. Upon arrival crew members discovered two persons had been shot. Per SOP, they called for a second unit and requested an "all call" be broadcast for all off-duty personnel and to place all county EMS units on standby.

     Once this call was complete, as VTRS3 and the responding second unit, VTRS2, were getting back in service, police radio reported a mass shooting at Norris Hall. Having all personnel already at VTRS base saved time and increased the number of units available for a fast response.

     The incident command system (ICS) provides structure and works well for organizing a frenzied scene. In 2004 the ICS was integrated into the National Incident Management System (NIMS). It is required by federal law to be used at all incidents regardless of type or size. ICS can be utilized by that first-on-scene crew to get the ball rolling, as long as they don't allow themselves to become rattled. Read, learn and practice your organization's protocols until they are firmly fixed in your mind.

COMMAND
     The sooner a command post is established, the smoother your incident will function. A command post can be anything from a chief officer standing in a parking lot with portable radios to a flag-waving command vehicle complete with staff. Once clearly established, it must be made known to all.

     Based on what VTRS personnel overheard on the police radio, they established an EMS command post at the VTRS station. The EMS CP utilized three radio frequencies to divide the radio traffic into similarly tasked groups. The response to the shootings was huge, involving 14 agencies with 120 personnel. However, not having a unified command caused some confusion among the EMS responders.

     In assuming command, one takes on the responsibility of requesting additional units, implementing a safe plan, following agency protocols, directing units and monitoring the situation until relieved by a higher-ranking officer. It is an enormous duty for a paramedic who happens to be first on scene.

     At NIU, a DeKalb Fire Department battalion chief was driving through campus when he was flagged down by three women who reported the shooting. He immediately radioed a first alarm, and when the scope of the incident was known, radioed for a general alarm and set up a command post in the parking lot, using his vehicle, which also served as a staging area. His command vehicle was soon replaced by an FBI command van and a unified command post that made excellent use of the radio system in controlling the various agencies operating on different frequencies.

     The command post coordinates and controls the action and is the pivotal point in any incident. A good CP helps calm a tense situation and prevents freelancing and disorganization.

     During the October 1991 Luby's restaurant massacre in Killeen, TX, a mutual aid agency responded independently to the scene. They set up their own triage/treatment area without regard to the efforts already established. This added to the confusion, and many tasks already accomplished were redone. At one point a freelancing EMS crew packaged a patient and was preparing to transport when a doctor stepped in and stopped them: The patient had been triaged earlier as deceased.

     A rather simple problem that came to light during the Luby's and Virginia Tech massacres was that the portable radios did not work from inside the buildings, or were unreliable. It only takes a few minutes to walk into a building and test your portable radios.

TRIAGE
     Triage is covered on one or two pages of most EMS training manuals. Some manuals encourage personnel to have EMT-Bs or higher make triage decisions; others support the START method. No matter what method you use, triage should be carried out by experienced personnel only. It is too important to be left to a freshly minted provider.

     At Virginia Tech triage was initially carried out by two tactical medics who triaged people in stairwells while police dealt with the shooter. Once the shooter was down, four VTRS medics joined the tac-medics in triage. Patients were found in several different classrooms and locations, necessitating more initial triage personnel.

     In mass-shooting incidents, take a mind-set of "keep initial triage simple" (KITS). Rescuers performing initial triage should not get bogged down in patient care. Having a method to use in performing triage allows for more uniform assessments. The START method provides a model that takes no longer than 60 seconds per patient to use. Gunshot wounds, by nature, are gruesome and can shock your thought process. Employing an experienced paramedic is instrumental in maintaining a focused, clear mind-set that facilitates the greatest good for the largest number of patients. Triage requires experience to determine not only the living from the dead, but also to identify those who have suffered life-ending injuries.

     When I was triaging victims in the Luby's massacre, I located an elderly man with a gunshot wound to his chest. He was pale and cyanotic, with ragged respirations, weak pulse and poor perfusion. As he reached out toward me, I knew from experience that his wound was fatal. I had combat experience (Vietnam 1968-69), and I'd treated many gunshot victims since becoming a firefighter/paramedic. I had to triage this victim as unsalvageable. It was one of the hardest things I've ever had to do. When I was told by the doctors that even with surgery this person would have died, I did not feel any better.

     Triage tags are a good idea, and most everyone in EMS recognizes that red is critical, yellow is less critical, green is minor and black is unsalvageable. However, it takes time to select the right color, fill each tag out and tie them to patients. This task may be better handled in secondary triage or treatment areas. At NIU triage tags were not used because crews were too busy. At Virginia Tech medics performing triage ran out of tags and resorted to colored tape. This led to some confusion, as not all patients had tags, and ribbons were not understood. Find the right system or method that works best for your community, and practice, practice, practice.

DOCUMENTATION
     Documentation during a mass-shooting incident is one of those things you don't think about because you're too busy. Having a written record of the incident is more than just creating a timeline.

     Individual patient records may be delayed during the triage, treatment and transport phases of the incident but should be completed as soon as possible. With all the turmoil that accompanies a mass shooting, you can forget what treatment you provided to what patient.

     Good radio communications with your command post or dispatch center can establish a timeline of when patients were transported and where they were taken. The command post should be responsible for creating a record of the incident, while individual EMS crews should be responsible for individual patient records. Comprehensive documentation of each phase of the incident is the best defense against any litigation that may arise. Documentation must include as much detail as possible. Remembering what you did last week may be easy now, but one year from now you'll need that report to refresh your memory.

     Proper documentation should include the "stuff that went right" and the "stuff that went haywire." When you finally sit down to write the report, stick to the facts and avoid embellishing the report with tales of heroism. This type of reporting can do you more harm than good.

     Each person who took part in the incident should be encouraged to write out a narrative, as soon as possible, that can be attached to the incident report. This will serve two purposes: It will contribute to a more complete picture of the incident, and it will allow the individual a chance to tell his/her story, an important step in dealing with stress.

DEFUSING/DEBRIEFING
     Taking care of your personnel post-incident is just as important as training beforehand. The well-being of personnel is fundamental to EMS, and caring for it is just good management.

     Holding a defusing session within a few hours of the incident is an excellent way to identify any potential problems. Talking about the incident helps you see how your personnel are handling any post-incident stress. I would rather identify a problem in a defusing than watch one angrily acted out in the station. Personnel need to know how they fit into the big picture and how important their role was in order to begin to heal. I know from personal experience that being told to "just get over it" is not the way to go.

     A formal debriefing can be held a couple of days following the incident but should not be thought of as a onetime fix. Additional debriefings can be held as needed.

     Through good, solid training and realistic, honest practice, the next disaster you respond to can be handled in the professional manner on which EMS prides itself.

Robert L. Kelley is a firefighter/first responder for the Gatesville (TX) Volunteer Fire Department. He worked as a firefighter/paramedic for the Killeen (TX) Fire Department from 1982-97. His article Killeen Diary, which detailed his experiences responding to the October 1991 Luby's shooting, appeared in the March 1992 issue of EMS Magazine. The mass shooting, in which gunman George Hennard killed 23 before shooting himself, was the deadliest in U.S. history before Virginia Tech.