Target Audience

“What a beautiful spring evening!” The Attack One crew is on the front ramp at the station on a Friday evening that’s much nicer than typical for spring. The conversation is casual until they hear a gunshot in the distance, and then another, and then a series of shots from a semiautomatic weapon. The sounds come from 6–8 blocks away, and they can’t help but move toward the Attack One vehicle, move it to the front ramp and close up the station in preparation to leave. Then even more shots ring out, followed by the sirens of several police cruisers, and the Attack One crew knows they will be needed shortly. As they progress slowly in the direction of the sounds, the dispatcher tones out a report of a “child shot.”

“Further information for responding crews, scene not safe, further shots still being fired. Caller is unclear about age and condition of child.”

This type of dispatch creates a great deal of tension for the crew. The address of the victim is very close to their location, and about half a block from a major street where a number of bars are present and sometimes filled with rowdy crowds on Friday evenings. The Attack One crew leader is considering a safe place to stage until they can be cleared by law enforcement to enter the area. Police sirens now seem to be coming in all directions, and the occasional sounds of gunshots still pierce the evening air.

They decide to place the vehicle on the major street, away from the bars and about two blocks from the caller’s address. They move in that direction until the radio crackles with further information from the dispatcher. There are now reports of several more victims, including a police officer. Their locations are on a variety of streets in the area, and one victim is in one of the bars.

The Attack One crew leader notifies the dispatcher of arrival in the staging area and calls the battalion chief just assigned to the incident. “Chief,” the medic tells the battalion chief and dispatcher, “we are closer to the address for the child who’s injured, and farthest from the site of the police officer. We are staged, so we will take the opportunity to notify the trauma center. Since that hospital is very close to this area, we will ask them to prepare security and expect multiple victims.”

The battalion chief then addresses the other crews moving toward the scene, making sure all units stage in areas away from the police activity and preparing the crews that would treat the injured officer. He tells all units he will be in direct communication with the police officer in charge, that only he will release the fire-EMS units into secured scenes, and that all units will report to Attack One as transportation director to coordinate victim removals.

The dispatcher updates all crews with information the communications center has received from callers. There are at least five victims plus the police officer, and in locations 4–6 blocks apart. There must have been multiple shooters, but as yet there are no descriptions of cars or individuals that may be responsible.

The battalion chief comes on to the dispatch channel: “All units may move into the dispatched locations. Police units have secured all areas. Be aware that no suspects have been apprehended, so stay alert for further information. Attack One crew leader will designate all transport destinations.”

Attack One proceeds to the site of the injured child, a home in a residential area, where the crew finds the parents, who tell them the child is 9 and was “shot in the upper leg.” They report the child was on the main street on a bicycle when he heard loud noises and felt something enter his leg. The parents heard the gunshots, ran toward the street and found their child. Since the shots kept coming, they carried the child back to the house and hid in case the shooters came down the street.

The Attack One crew members find the child in the basement; he is awake and alert, although pale and tachycardic. He has a single wound to his right upper leg, but it does not look like a bullet wound. There is moderate bleeding, and he has a weak distal pulse in that leg. No other wounds are found. His bleeding is controlled by direct pressure. There is no gunpowder staining of the wound.

The Attack One crew leader assigns his crew to dress the wound, the paramedic to set up and start an intravenous line in the ambulance, and everyone to expedite a rapid load and transport to the hospital.

He communicates with the battalion chief: “Sir, our victim is red category, and we are initiating transport. I will serve as transport director and assign crews as they complete assessments of the other victims.”

“Command to transport,” the chief responds. “Clear on your duty to assign crews as they complete assessments of other victims. You are also to track victim names and where they were injured and transported from. I have assigned a captain as safety officer, and another as liaison to the police department. The shooters are unknown, and there may be further victims. I have requested a total of 10 ambulances, and a lieutenant is serving as staging officer, with the resources staged at the local police precinct parking lot.”

Then a fire officer from the first-arriving engine at another scene calls in.

“Main Street Sector to Command,” he reports, “we have two victims at this bar; one is a police officer. He is red category, and the other victim is yellow. Requesting two ambulances immediately and another to stand by, as we still have a lot of police activity here.”

“Main Street Sector, clear on two victims, one red and one yellow,” Command responds. “Assigning you Medic One and Medic Four immediately, and Medic Six will be your third ambulance in. Contact transport director for transport destination. Operate with your crew safely, and take cover immediately if further violence occurs. A safety officer has been assigned.”

The other first-arriving crews report to Command, and ultimately the tally is seven victims being assessed by fire-EMS personnel. They are scattered across five locations in the neighborhood.

“Liaison officer to Command,” the captain working with the police leadership calls in. “One of the current victims is likely one of the shooters. There are at least three other suspects in a car that are not in custody, and there is a potential for more victims and high-risk police activity. Police are interviewing the suspect in custody.”

Then, from the Medic Two crew leader: “High Street Sector to Command, we have assessed that victim, who is yellow category and stable, and in police custody. They are interviewing him, so our transport will be delayed. We will have two police officers accompany us to the hospital.”

“Command to High Street Sector, clear on one yellow victim in police custody, and per protocol make sure there is at least one officer in the patient compartment with you, and he has no weapon, but has keys for the handcuffs. Have a squad car follow you to the hospital. Transport director will assign the hospital.”

“Transport director to Main Street Sector and High Street Sector,” the Attack One crew leader comes back. “Each of your victims is to be transported to the trauma center, which has been notified. No radio traffic is needed to them. Security has been notified at the hospital.”

One by one, the other victim reports crackle across the radio. Six of the victims will be transported to the trauma center, and one yellow victim will go to a nearby hospital.

The paramedic caring for the police officer returns with some critical information: “Main Street Sector to transport director, the police officer is red category, and we need the trauma center to be prepared for his care. He has a bullet wound to his left upper leg that was bleeding profusely, and another officer applied a belt to tourniquet the wound. We replaced that with a formal tourniquet, as we cannot control the bleeding with direct pressure. His vest was struck several times in the abdomen and chest, but he has no visible wounds to the torso, and no tenderness. He is awake and talking with us, but is in significant pain in the left leg.”

 “I will report the patient to the trauma center,” the Attack One crew leader advises. “Clear on red category, bullet strikes to the vest but no torso injury, and a tourniquet on the left leg for a severely bleeding wound.”

The Attack Crew transports the child victim and organizes the transport operation. All victims are transported to the two hospitals, and no further victims are reported through the liaison officer to metro police.

Hospital Course

The victims arrive at the emergency department over about 20 minutes. The child’s wound is examined by the trauma surgeon, and a rapid x-ray confirms it is not a bullet wound. It is a piece of brick or cement block, no doubt kicked up by a bullet, and has damaged the femoral artery. The child is stable, but will undergo vascular surgery at some point.

The police officer has a significant injury to his left leg, and will be moved immediately to the operating room. Bullets hitting his protective vest caused contusions to his chest wall and abdomen, but no internal injury.

One of the victims with a gunshot wound to the shoulder is treated in the ICU due to bullet entering his chest. A victim with bullets to the buttocks and upper leg and arm is also taken immediately to the OR. This man had a bullet strike his buttock as he ran from the shooter. The bullet entered his abdominal cavity, and his condition worsened while in transport. On arrival at the trauma center, he began to complain of abdominal pain, and his abdomen became very tender.

All victims survive their gunshot wounds and are ultimately discharged from the hospitals where they received care.

The event occurred as a result of a fight at the bar that extended out across the city. The shooters were eventually found and chased until they crashed their vehicle. Another multiple-victim incident occurred as a result of that accident.

Case Discussion

Gunshot wound victims are difficult to assess in the prehospital environment. The wounds may appear to be very minor, with little bleeding, when in fact there are devastating internal injuries that will end the victim’s life. There are also victims who appear to have significant external injury but have little or no damage to important internal organs. The victim with a gunshot wound to the lower back and buttocks, like the one in this incident, will often have penetration of the bullet into the abdominal cavity. When you look at yourself in the mirror next, notice that your abdominal cavity extends from your nipple line to the bottom of your buttocks. Penetrating wounds of any type in that zone can enter the abdominal cavity.

It is also critical to note that bullets do not pass through the body in a straight line, and have essentially an unlimited ability to bounce around inside the body once they enter. A full assessment is needed of each area of a GSW victim’s body.

When violence involves multiple victims and the incident is scattered across a wide area, EMS crew safety is at particular risk. There have even been incidents where rescuers were targeted. Multiple-victim incidents with significant trauma require timely response, on-scene treatment and rapid transport to the closest appropriate trauma center. Rescuers must make every attempt to respond in a timely manner, but use a very cautious and integrated approach to scene safety with local law enforcement.

Law enforcement personnel injured in the line of duty should provoke a higher level of concern and the respect of those protected by officers who put themselves in the line of fire. This incident clearly illustrates the need for cooperation with law enforcement and an integrated command function. The battalion chief was in face-to-face contact with the lead police official as they coordinated where police officers had secured scenes and where EMS crews were needed. There was one individual suspected to be a shooter, and he had to be subdued by officers and then secured before EMS could transport. The officers wanted to interview him quickly in an attempt to identify the other shooters, so after his initial triage EMS providers let the officers do their work prior to transport. Law enforcement officers are responsible for escorting a criminal suspect to the hospital, to avoid a situation where that individual becomes uncooperative and EMS providers do not have law enforcement powers to restrain.

An injured law enforcement officer requires excellent and timely care and the cooperation of other law enforcement officers to remove and secure his/her weapon and ammunition, assist in removing any protective vests or body armor, and provide communication to supervisors.

James J. Augustine, MD, FACEP, is medical advisor for Washington Township Fire Department in the Dayton, OH, area. He is director of clinical operations at EMP Management in Canton, OH, a clinical associate professor in the Department of Emergency Medicine at Wright State University in Dayton, and an editorial advisory board member for EMS World. Contact him at jaugustine@emp.com.?