Virginia Tech Mass Shooting Review Panel Report

Disclaimer: The information presented here is based on the report of the review panel convened by Virginia Governor Timothy Kaine to examine the mass shootings at Virginia Tech. It does not reflect the beliefs or opinions of the Virginia Office of Emergency Medical Services or Department of Health.

Introduction
     On April 16, 2007, Seung-Hui Cho, a senior at Virginia Polytechnic Institute and State University (Virginia Tech) in Blacksburg, VA, murdered 32 students and faculty and wounded 17 others in two related incidents comprising the worst school shooting in American history.

     Three days later, Virginia Governor Timothy M. Kaine commissioned a panel of experts to investigate the tragedy and recommend improvements to Virginia laws, policies, procedures, systems and institutions to help prevent similar incidents in the future. The panel was officially established in June through executive order.

     Each member of the panel had expertise in areas pertinent to the investigation, including public safety and security and emergency medical services, among others. Their findings and recommendations were released to the public on August 30. The following outlines the panel's findings, particularly with regard to emergency medical services response.

Scope
     The panel was directed to examine how Cho carried out such a violent act; recreate a timeline of events at the shooting sites, West Ambler Johnston dormitory and Norris Hall; and review the response of the agencies involved in the event, including the emergency medical response. Panelists were to recommend measures to improve the pertinent agencies, systems, laws, policies and procedures based on their findings.

     The panel used several different types of research and investigation methods to conduct its examination, including literature review, interviews, public meetings, and websites and e-mail. Nearly 2,300 people contributed opinions or input during this process.

Chapter IX: EMS Response
     The chapter of the report that primarily deals with the EMS response is one of the longest chapters in the report. It discusses prehospital treatment, transport and the hospital care of the wounded patients, as well as transport of the deceased. In addition, the panel was tasked with evaluating the on-scene EMS response, implementation of mass-casualty and ICS plans (including NIMS compliance and patient stabilization) both in the field and at the hospital, the types of communications systems used and coordination of resources. The introduction to the chapter praises the overall EMS response and commends those providers who responded and rendered care. The Virginia Tech Rescue Squad (VTRS) and Blacksburg Volunteer Rescue Squad (BVRS) are both singled out for their actions.

West Ambler Johnston Hall response
This section of the report outlines the response to the West Ambler Johnston Residence Hall, the scene of the first two murders. VTRS was initially dispatched for an injury from a fall, and the VTRS crew arrived on scene within five minutes of dispatch. Providers found a tragic scene: two patients with gunshot wounds to the head. A medevac was initially requested, but denied due to inclement weather. Both patients were assessed, immobilized and treated quickly and aggressively. Both were transported from the scene within 15 minutes of VTRS arrival. One patient went into cardiac arrest en route and was pronounced dead on arrival at Montgomery Regional Hospital (MRH). The other arrived at MRH and was intubated in the ED, then transported to Carilion Roanoke Memorial Hospital (CRMH) in Roanoke. During that transport, that patient also went into cardiac arrest, and was pronounced dead on arrival at CRMH.

     The report concludes that the triage, treatment and transport of the two patients from West Ambler Johnston was appropriate, and that both victims' injuries were incompatible with survival.

Norris Hall response
Shortly after returning to service after the first incident, VTRS crews overheard police radio traffic advising of an active shooting at Norris Hall. At that time, a VTRS officer assumed EMS Command and established an incident command post at the VTRS station. VTRS also contacted the Montgomery County EMS Coordinator to place units outside the campus on standby. At that point, the Montgomery County communications center paged out an "all call," requesting any available units to respond to Norris Hall. This order was quickly corrected by the county EMS Coordinator, and agencies were requested to stage at BVRS.

     Four minutes after overhearing the radio traffic, VTRS was dispatched to Norris Hall for multiple shootings. The EMS Commander advised any units responding from outside the Virginia Tech campus to stage at BVRS, rather than coming directly to Norris Hall. Authorities both on campus (the Virginia Tech Police Department) and off (the Montgomery County Communications Center) issued separate EMS dispatches for resources, which led to some confusion among EMS responders.

     VTPD arrived at Norris Hall three minutes after dispatch. Five minutes later, emergency response teams from VTPD and Blacksburg Police arrived on scene, each with a tactical medic. Those teams immediately entered the building, and two minutes later, the medics began triaging patients police were bringing to them. Walking wounded and those who were able to be carried or assisted out of the building were led to police SUVs for further assessment and treatment in a safer location.

     The two tactical medics proceeded through the second floor of Norris Hall, where the majority of the shootings occurred. The report recognized the efforts of those medics in identifying viable patients, as well as initiating rapid interventions that possibly saved lives.

     Twenty minutes after arrival on scene, VTPD announced that the shooter was down and that EMS crews could enter the building. The EMS Command assigned a Triage Officer, and triage of patients continued both inside and outside Norris Hall. Critical patients were transported to local hospitals via ambulance, and noncritical patients were moved to a secondary triage area. Providers confirmed 31 people were dead, and the decision was made not to attempt resuscitation. No one appeared to have been mistriaged. Additionally, there were no reported injuries of any law enforcement or EMS personnel.

     Interviews of prehospital and hospital personnel indicated that triage tags were used on some patients, but not all. Not using the tags may have led to some confusion regarding patient identification and classification upon arrival at the hospital. None of the tags were available for review by the panel.

     Just over an hour after the initial dispatch, all patients from Norris Hall were transported to hospitals or moved to secondary treatment units. In addition to VTRS, 14 agencies from the area responded to Virginia Tech that morning to transport patients, and additional agencies provided interfacility transportation of critical victims. Twenty-seven ambulances and more than 120 EMS personnel were utilized, and assisted with coverage through established mutual aid agreements. The review panel noted the "exceptional working relationships" of the involved entities.

     The panel report goes into some detail on the EMS Incident Command System (ICS) utilized at Virginia Tech. That ICS structure was based on NIMS guidelines, using an EMS Commander, Triage Officer, Treatment Officer and Staging Officer. The panel reports that though the ICS structure didn't strictly follow NIMS guidelines, it did include the necessary organization.

Lessons Learned, Good and Bad
     The report contains over 70 key findings. The chapter addressing the EMS response contains 21, both positive lessons and areas for improvement. Among these are: Positive Lessons

• EMS responses to both scenes occurred in a timely manner.
• Patients were correctly triaged and transported to appropriate facilities.
• The incident was managed in a safe manner, with no reported injuries among responders.
• Local hospitals were prepared for patient surges and managed those patients well.
• All patients who were alive after the Norris Hall incident survived through hospital discharge.
• EMS agencies demonstrated an exceptional working relationship, which was likely an outcome of training and drills among the agencies.
• The overall EMS response was excellent, and the lives of many were saved that day.

• There was a delay between VTRS's monitoring of the incident and its actual dispatch to Norris Hall.
• Radio traffic occurred on multiple frequencies, leading to issues regarding vehicle staging and clearance into Norris Hall.
• Triage tags were used on some, but not all patients.
• Police ordered transport of deceased patients under emergency conditions.
• The lack of a unified command post.
• Communication issues and barriers led to frustration during the incident.

Additional Items
     Later that afternoon, the medical examiner authorized the removal of the deceased from Norris Hall to the medical examiner's office in Roanoke. Several options were considered, including the use of refrigerated trucks, funeral coaches or EMS units. It was decided that, though not generally used for transports of the deceased, EMS units would be acceptable, being that 9-1-1 response to the area would not be compromised, and that refrigerated trucks and funeral vehicles on campus may be undesirable. An unidentified police official issued an order that EMS vehicles transport the decedents to Roanoke under emergency conditions (lights and sirens). In the interest of safety, EMS command opted not to honor that order.

     Critical incident stress management activities such as defusings and debriefings were made available to all responders immediately post-incident.

Hospital Response
     Twenty-seven patients were treated at area hospitals. The report says it's unknown if individuals involved in the shootings may have been treated at other hospitals, clinics or doctors' offices. Most of the hospitals involved initiated internal ICS and mobilized internal resources in anticipation of potential patient surges. Patient injuries ranged from gunshot wounds to asthma attacks, fractures and even burns.

     The report notes that a lack of communication between the scene and area hospitals presented a challenge, as hospitals didn't know how many patients they'd be receiving.

     Of the patients transported via EMS, only the two initial victims from West Ambler Johnston died in or prior to arrival at the hospital.

Emergency Management
     This section of the report reviews the relationships among the state, regional and local authorities involved in the incident at Virginia Tech, including agencies created to facilitate coordinated emergency response in both the hospital and prehospital settings.

     The report notes that the regional MCI plan was used correctly, but that the use of multiple radio frequencies, a lack of unified command, and communication with the hospital by many different sources, instead of through the ICS, created some confusion during the course of the incident.

Recommendations
     The panel makes 10 recommendations based on its findings. Most focus on improving the coordination of resources during MCI responses, holding disaster drills on a routine basis, and continuing to make CISM available to providers as needed.

Summary
     The events that took place at Virginia Tech shocked a nation. The EMS responders who answered the call that day were responsible for the treatment and transport of 27 patients, several of them critical, and their expedient response likely saved the lives of many.

     As with many mass-casualty incidents, there are after-the-fact findings and recommendations for improvement, but the lessons learned through these tragic events may assist future responders.

     See the full report at www.governor.virginia.gov/TempContent/techPanelReport.cfm.

Timothy J. Perkins, BS, EMT-P, is the EMS systems planner for the Virginia Department of Health's Office of EMS. He has over 17 years of EMS operations and management experience. E-mail him at tjperkins5@yahoo.com.