Case Review: Officer Down

The morning is quiet. Station duties, and a quick training exercise on the use of the new textile devices that can be used to move large persons, are completed.

The urgency of the dispatcher’s voice is evident from the first syllables.

“Officer down, active shooting event, Signal 99 for law enforcement. County courthouse, stage away from the scene. Attack One respond.”

The Attack One officer processes the words in her head, and silently recites in her mind, “This is not a drill.”

Understanding the communications center will be completely committed to law enforcement activity, the battalion chief takes responsibility for immediately calling for three additional paramedic units, extablishing a staging point three blocks from the courthouse for all fire and EMS units, and designating a tactical channel for all fire EMS communications regarding the incident. A second battalion chief will respond as the safety officer, and a ladder truck will be dispatched to serve initially as staging command.

Before they can arrive at the staging area, Attack One is routed into the scene, at the request of the ranking law enforcement officer (LEO) on the scene, who makes the request directly on the EMS radio channel. The battalion chief asks the officer if the scene is safe for entry, and the LEO reports, “No sir, but we have an officer down on the street north of the courthouse, with severe injuries.”

The battalion chief confirms the communication with the LEO, and makes sure the Attack One crew understands they will be the only unit entering the area, and to take all necessary precautions to protect themselves, while scooping and removing any victim as rapidly as possible.

The Attack One crew leader sets the priorities immediately for the three person crew.

“Don your helmet and your turnout jacket. The only equipment on us will be tourniquets, a bag of trauma dressings, our trauma scissors and one of those textile devices we just trained on. We will pull up to a protected area half a block away, run to the scene with those rescue items only, and plan to grab the victim and carry him or her back to some protected area near the vehicle. No delays allowed.”

The paramedic places a rapid call to the medical direction phone at the trauma center, which is close to the scene.

“Please place yourself on Alert status. We have no details, but are responding to an active shooter scene with the report of one serious injury and an ongoing event at the courthouse. Monitor traffic and we will get you any patient details if we can.”

Attack One approaches and finds three officers, with guns drawn, protecting an officer who is prone on the sidewalk. There is blood visible on the ground as they run in with their streamlined equipment. The officers give a rapid report, that at least one individual was shooting inside the courthouse where there are more casualties. This officer was not on duty yet, so was not protected by body armor. As he walked toward the courthouse, the shooter bolted out of a door and shot the officer without warning. The criminal continued to run, but they do not have a direction or a good description of the criminal. This officer has been unconscious since the other officers arrived.

They note the officer was shot in the upper abdomen and in the face. He was not responsive to verbal directions, and his airway and breathing are compromised.

The paramedic proceeds quickly to load the officer onto the textile sheet. A trauma dressing is placed over the abdominal wound, and one over the facial wound. The LEOs are advised that the injured officer will be carried half a block away, where they will rendezvous with a transport ambulance, and the officer will be transported immediately to the trauma center. The officers are requested to provide ongoing security for the crew, and at least one to accompany the paramedic transport unit.

Command is notified by the paramedic. The Attack One crew is to remain on the scene with the officers, and let the transport unit proceed quickly to the trauma center with its’ own crew. Command has been advised that two more LEOs have been shot inside the courthouse, and the Attack One crew will be responsible for triage and initial care until further law enforcement work can provide a safe environment for the remaining rescue crews to work.

The mortally wounded LEO is carried to the ambulance, loaded quickly inside, a report is given to that crew, and one armed law officer jumps in the ambulance to provide information, guidance and any necessary protection to that vehicle and its EMTs.

The Attack One crew returns to their vehicle, replenishes their rapid care equipment, clean up the blood from the two law enforcement officers who are with them and ready themselves for their next triage duties. The remaining EMS resources are staged several blocks away, ready to proceed in when there is enough sufficient control of the scene.

The Attack One crew is led to the front door of the courthouse, and then into the front lobby. There they find two patients, both LEOs with wounds to their legs. They were shot, but both had protective vests in place. One complains of chest pain, and other officers have determined he was shot in the right chest, but the bullet did not penetrate the body armor. But both have injuries in the thigh, and both have a trauma tourniquet in place on the involved leg. There are no other obvious wounds, and both are speaking and trying to give necessary information to the officers who will be attempting to locate the shooter.

Command is notified that two transport ambulances will be needed immediately and a rendezvous point is established near the front of the courthouse, where a large number of armed LEOs are clearing the area and preparing a safe zone for EMS operations.

The paramedic quickly identifies that the injured officers have no further wounds, but both have holes that are close to the arteries in the upper leg so there is no reason to remove the tourniquets in place on each officer. They are reassured the ambulances will have pain medication for them, as the placement of the tourniquet has now resulted in significant pain for both.

They are loaded onto sheets and carried outside to the ambulances.

The paramedic is advised by the lead law enforcement official that the area directly in front of the courthouse is now a safe zone, and requests that fire and EMS resources, and the battalion chief, be put in place as rapidly as possible. Since there are ongoing life threats, the battalion chief will be incident command, and law enforcement will organize themselves in the operations sector. The paramedic quickly communicates that information to the battalion chief, and soon the complete set of EMS and fire resources are in place at the front of the building.

More patients are being brought to the lobby of the courthouse, with a variety of complaints related to taking cover from the gunman, including from running down steps or falling in the pandemonium. The Attack One crew is in place to perform triage and now have a number of fire and EMS personnel to assist. There are no further gunshot wounds and on initial assessment no other severe injuries or illnesses.

Command has been establsihed at the chief’s car. Law enforcement believes there is only one gunmen who is acting alone, and that he shot a number of people in the building, then exited and shot the officer who may not have even known there was an event occurring. There is no obvious additional criminal problem in the building. But many courthouse employees have barricaded themselves in rooms in the building and there is no single PA system that will contact all of them. The operations sector is developing an action plan to sweep the entire building, to look for victims, secondary devices and any other threats. They will also liberate the persons who are barricaded in offices and rooms.

Law enforcement officers believe fire personnel are better skilled at moving through the building quickly and in an organized fashion to locate other problems and do the rescue operations, but each group of fire personnel will be accompanied by an armed officer. They will also safely perform any breaching operations needed to open locked doors.

Command establishes the objectives over the radio. “Each entry team will perform a search in their designated sector only, and accompanied at all times by at least one armed officer. Any victims will be carried or directed to the first floor lobby, where hot zone triage will be performed. All crews will maintain their members at all times, and not move as individuals at any point, to avoid problems with law enforcement operations. As assigned sectors are cleared, report to command. Move quickly and safely.  Identify and move away from any objects that may be secondary devices.”

The Attack One crew members are assigned as triage, and other EMS officers are designated as the transport sector command.

The transport command officer has the responsibility to determine transport hospital receiving sites, make contact with the hospitals and track the removals. Treatment sector will care for all persons who need on-scene care, such as those individuals who have minor ailments related to the evacuation process.

An initial group of EMS personnel and an officer are assigned to tactical responsibilities, to provide care for any further LEOs who are injured, and to support the operations in the building and surrounding areas where the search is on for the gunman. A fire crew is assigned the responsibility to mitigate any fire dangers and any secondary devices that are found.

Transportation and Hospital Course

A total of three victims are transported from the initial operation. There is the possibility of further victims as the building is searched and the manhunt for the perpetrator takes place.

The victims all go to surgery, and two of the three survive.

The on-scene operations progress and the building is cleared over the next hours. There are several dead persons in one of the court rooms. No further victims are identified with serious injuries, and a total of five additional victims will ultimately be transported to hospitals for minor illnesses and injuries.

Organizing Patient Assessment

Many fire and EMS organizations use triage systems that result in patients being numbered in sequential fashion. The Emergency Assessment box (Figure 1) represents the results of that triage process. The crews triaged eight patients and categorized the patients by the compromise of the ABCDE body systems.

Case Discussion

With the latest incidents that have occurred across the United States and around the world, emergency scenes have an ever wider range of potential threats. But the fire EMS services have a lengthy history of managing hazards of all types using the Incident Command System, and those principles prepare emergency personnel for any type of incident. Regarding EMS victim care, they’re a structured set of principles that save lives, whether a bomb has been detonated, thunderstorm winds have just collapsed a stage onto a big crowd or someone is still shooting. When the incident involves ongoing violence from gun, bombs or fire there is another set of priorities that are related to combat medicine.

An “active shooter event” involves the management of an incident where there is real or potential ongoing violence. The planning for these events requires a high level of cooperation and a joint Incident Action Plan developed by local law enforcement and fire EMS leaders, and followed by training for all levels of public safety personnel. There are fortunately a growing number of programs that allow school teachers, workers and others to “shelter and fight” to save lives as these incidents first evolve. These are also integrated with law enforcement.

Scene Priorities at an Active Shooter Incident

Public safety providers have a joint opportunity to save all lives possible. Law enforcement has the primary responsibility to neutralize a person or persons with weapons of any type. Their responsibility and training constitute the first wave of responders into the scene. All public safety personnel share a responsibility to perform rescues and operate in a way that maximizes safety for their own personnel.

Active shooter incidents can, of course, have the full range of injuries and illnesses. The majority of life threatening injuries will involve serious or lethal penetrating wounds with ongoing hemorrhage. EMS emergency care should prioritize the control of hemorrhage. Relatively less spine immobilization is needed, and personnel should be equipped to move patients quickly using blankets or similar equipment and devices. Triage is simplified, without need for fancy devices. In these circumstances, rapid BLS care is the EMS strategy. Airways will usually be managed after the victim is moved to a safe area in the cold zone, and after hemorrhage control has occurred using tourniquets or trauma dressings.

There are very important “rescue equipment” considerations for active shooter incidents. EMS personnel must enter the scene with a simple and effective set of tools, leaving the stretcher, bigger bags of equipment and monitors in the outside casualty collection point. Some systems have created a small bag marked as “Trauma MCI Bag.” The needed elements may be as simple as:

• A number of large size non-sterile gloves;
• Commercial tourniquets in sufficient quantity for the ingoing personnel;
• Trauma dressings for wounds that need to be packed;
• Trauma scissors;
• Blankets, sheets or other textile devices to grab and move patients quickly, or cover victims who are unclothed, or to be cut apart with the trauma scissors to use as dressings;
• Some systems have a set of oral airways and a device to decompress a tension pneumothorax; and
• Triage tags and a magic marker.

In the active scene area, the priorities are to stop bleeding and get the patient out to a casualty collection or transportation point. Rapid evaluation and a few critical interventions will minimize the loss of life among those that are seriously injured. Most medical triage systems—START, SALT and others—allow for that medical work to occur in a few seconds with just a pair of gloves. With the small cache of equipment lifesaving hemorrhage control can be accomplished, and the patient rapidly pulled or moved out of the hot zone to a secured area before rapid transportation to a hospital. En route to the hospital, or in the event of delayed transport or prolonged extrication, there is the consideration of using advanced life support interventions like definitive airway management, IV lines and pain medications.

There must be early implementation of a plan for patient transportation. Communication must be made as early as possible to potential receiving hospitals, even if no specific patient details are available. A critical element of active shooter incidents is the ability of hospitals to prepare surgical resources, and that requires a little time before the first arrival of seriously injured patients. All hospitals must be prepared for these incidents, as designated trauma centers may not necessarily be the closest and most appropriate first receivers.

Victim transportation must be expedited. Some jurisdictions use police transport of victims, but a more sensible plan is for law enforcement personnel to do their work, and EMS personnel to treat and transport patients. Transport of patients by medical helicopters is generally not an option in these incidents, so ground transport to the closest appropriate hospital will be the rule. There is one further consideration, related to incidents that have occurred around the globe. Some incidents have included an element of creating problems at the receiving hospital, to further the human losses. So hospitals and transporting EMS systems must keep weapons away from the hospital. For chaotic incidents with the potential for multiple perpetrators, EMS personnel must use processes that reduce the risk of transporting persons with weapons to the hospital.

The scene can be managed using a set of pre-event leadership agreements between law enforcement and rescue agencies. Many utilize the principles of “wave management.” It is clear that law enforcement is the primary element of the “first wave” initial entry into the building, with a primary aim to neutralize the threats that are part of the initial event and reduce the risk of secondary events. The first wave is followed by a “second wave” of fire EMS resources that are protected by the police personnel. It should be clear to the EMS rescue personnel that they are not to distract law enforcement from their role in protection, weapons management and investigation. It is not good procedure to have the police officers “pull off” to help do patient care or drag victims out, as they have other priority items to manage.

In the planning for these active shooter incidents, fire EMS personnel may have other scene management roles in the hot zone. The core competencies of fire rescue that may be critical in active shooter incidents include the firefighting principles of building clearance; the ability to identify potential explosive hazards; the responsibility to extinguish or mitigate fire risks; and skills in the use of thermal imaging cameras to hunt for victims, hazards or perpetrators. While doing patient care and these other responsibilities, fire EMS personnel have an ongoing responsibility to reduce the contamination of the hot zone, leaving the scene as intact and undisturbed as possible for investigators.

Fire EMS personnel should have a particular sensitivity for the presence of secondary devices intended to cause ongoing damage. In U.S. incidents over the last 20 years, there has been a very high incidence of the use of secondary devices. Public safety personnel are jointly responsible for identifying areas where those devices may be located and reducing the likelihood that they will cause further harm. One important note on communication systems: law enforcement may decide at a bombing incident to shut down the cellular phone network in the immediate area, to mitigate the risk of cell-phone activated secondary devices. Fire EMS providers, unless their phones are specifically equipped, will not be able to use the phones in the area as part of the incident response.

Priority Elements in an Active Shooter Program for EMS

• Planned approach integrated with local law enforcement
• Fire EMS personnel likely to be members of the “second wave” going into the scene
• Fire EMS personnel should be visible as rescue personnel, not law enforcement

Life Saving Scene Care

• Injuries are more likely to be serious or lethal penetrating wounds, with hemorrhage the most important life threat
• Control Hemorrhage
• Relatively less spine immobilization is needed, and more apt to be moved quickly using blankets or similar
• Triage is much easier, without need for fancy devices
• BLS rapid care is perhaps more important than ALS care

Transport Considerations

• Early communication to potential receiving hospitals
• Trauma centers may not necessarily be the first receivers
• Less use of medical helicopters for transport
• Consider means to reduce risk of transporting weapons to the hospital
• Some jurisdictions use police transport

Protect the Hospitals

• Notify as early as possible to allow needed preparation
• No weapons coming in accidentally or intentionally
• Early communication a necessity for hospital to activate a receiving plan
• Police transports may occur

Only Rescue Equipment that Needs to be Carried into the Scene

• Gloves available in large quantities
• Tourniquets on all ingoing personnel, trauma dressings, trauma scissors, and maybe oral airways and a chest decompression device
• Blankets or sheets to warm and move quickly, and cover if the victims are unclothed

Learning Point

A multiple casualty incident at an incident with continued concern about the perpetrator. The incident requires careful coordination with medical control and the distribution of patients to multiple hospitals. Scene management must be carefully coordinated with law enforcement, using NIMS principles, and with the understanding that priorities may change on a minute-by-minute basis.

James J. Augustine, MD, is an emergency physician and the director of clinical operations at EMP in Canton, OH. He serves on the clinical faculty in the Department of Emergency Medicine at Wright State University and as an EMS medical director for fire-based systems in Atlanta, GA; Naples, FL; and Dayton, OH. Contact him at jaugustine@emp.com.