Quality Corner: Using the Columbine Mile for Rapid Response Training

Mass shootings and explosive incidents, whether perpetrated by foreign or homegrown terrorists, are ever increasing in frequency and lethality. As a result police, as well as EMS, have had to dramatically modify their response. The Columbine High School shootings of 1999 was a seminal moment in active shooter mitigation. Since that time it is no longer always acceptable or practical for EMS to wait until the scene is safe. In reality, “scene safe” was always a misnomer. There is never a guarantee that even the most routinely dispatched of calls will be safe. We simply manage our response based on the best information we have and handle the call as safely as possible given the circumstances.

When responding to an active shooter incident, police now initiate an immediate action rapid deployment (IARD) tactic whereby the first arriving two or more officers arm up and head toward the sound of the shooting to actively pursue and neutralize the shooter. Patient care in the tactical environment is something SWAT and combat medics are well trained and prepared for, but for the rest of civilian EMS this is something as new as it is overwhelming.

If EMS does not preplan and prepare for mass shooting and explosive incidents, there will almost certainly be a greater loss of life than need be. But that begs the question, how do EMS agencies, many of which are small and whose resources are already stretched to the breaking point by regular daily operations, prepare for such doomsday scenarios?

While you can never prepare enough for something so dramatically different from your normal operations as a mass shooting or explosive incident, there are three things every EMS agency should immediately do.

First, EMS leadership should reach out to the leadership of local law enforcement to create an operational plan that establishes how EMS will be deployed and utilized in an active shooter or explosive incident situation. Having such an operational plan established and known by emergency responders will go a long way to instill comfort and confidence in all personnel. It will also dramatically improve the chances of successful mitigation of such an incident.

Secondly, all EMS responders should be provided basic tactical casualty care training. An excellent course for this is the Law Enforcement and First Response Tactical Casualty Care (LEFR-TCC) course, sponsored by the National Association of EMTs.

And finally, while impossible to fully prepare for an actual active shooter or explosive incident event, the tactical medics at Bucks County Rescue Squad designed a practical training scenario that probably comes as close as training can come. We dubbed this exercise the Columbine Mile. And as I explain to the students during the introduction, it’s not actually a mile long, it will just seem like it.

Scenario

The Columbine Mile is comprised of six to 10 moulaged patients in a stairwell, hallway, room or multiple rooms. They have a variety of wounds, which ideally should include at least three patients with major hemorrhage, with the remaining patients offering a combination of minor wounds, dead or unconscious and one or two hysterical patients. Add to this loud acoustics of your choice and strobe lights in an otherwise dimly lit room and you’ve created a high stress training environment.

The most difficult component of this training is to acquire victims. At Bucks County Rescue Squad we were fortunate enough to have our local Civil Air Patrol unit volunteer. Other potential sources for victims might be EMS Explorer Scouts or Boy Scouts, drama club members from the local high school or other members of your organization.

You can go totally crazy with moulage if you choose, but we kept it simple at Bucks County Rescue Squad. Simulaids now offers the sale of individual moulage wounds instead of the entire larger and more expensive kits. The average cost is about $50 per wound. We purchased three arterial bleeding wounds and three distracting injury wounds.

Any mass shooting or post-explosive incident environment is guaranteed to be chaotic, both visually and audibly. There will be screaming people, sirens and vehicle noise of arriving apparatus, as well as the cacophony of police, EMS and fire radios. There will also likely be a great deal of visual overstimulation in the form of strobing effect from arriving emergency vehicles. We chose to pipe in loud music.

As far as execution, the greatest training value of the Columbine Mile will be derived if the exercise is done by teams of two. This will maximize the stress and overwhelming workload of a real-world event. It will also represent the most likely scenario of the first arriving EMS unit with two providers being thrown into the breach.

The goal of the Columbine Mile is to quickly identify and save the lives of massive life-threatening bleeds, while bypassing all others. This should be made difficult in the Columbine Mile exercise by including non-life threatening distracting wounds, as well as minor injuries and screaming, blood-covered patients. You should also include a dead or unconscious victim or two.

The first scan should be for life-threatening bleeds only. Victims with non-viable wounds are easy; one glance and move on. Unconscious or dead without non-viable wounds should simply be rolled into the recovery position to aid them in surviving if they are survivable.

Any walking wounded should be directed to exit the building toward the arriving emergency vehicles or put to work holding direct pressure or applying tourniquets that can be thrown to them. Many such non-critically wounded patients can be quickly turned from victim to rescuer if simply told what to do. Putting these type of patients to work is immediately beneficial to them as it quickly and effectively reassures them that they are not that seriously injured. But the long term benefit may be most important since studies show that victims who aid other victims in a mass casualty incident do much better psychologically because of their actions.

Tactical medical training should be extreme, challenging responders to deliver patient care in under the worse conditions with nowhere near enough resources immediately available. It is therefore critically important to let participants know beforehand that the exercise is designed to stress and challenge them to the extreme and if they agree to participate they should not be afraid to fail in training since this is the quickest way to learn the most.