Response to Atypical Incidents: New Demands for EMS

EMS has always faced the possibility of responding to acts of violence, but as the world changes, new challenges and threats are presented that are more complex and hold more danger for EMS providers.

Recent events such as the terrorist attacks in Paris and San Bernardino make it imperative that EMS providers understand and adapt their response to these threats accordingly, to save the lives of victims and fellow first responders. New procedures must be adopted that reflect coordination within each community for the most effective response for its citizens.

EMS providers are accustomed to responding to violent incidents where guns, knives and other weapons have been utilized. However, over the past decade, EMS has faced a growing number of higher-level incidents—those involving active shooters, and also heavy weapons, terrorist attacks and the possibility of additional attacks that include explosives and hazardous materials. This trend demands not just a simple shift in response, but an entirely new thought dynamic for EMS.

For law enforcement, the Columbine school shootings was the sentinel event that changed their response to active shooter incidents. A lesson learned was the immediate need for first arriving officers to engage the perpetrators rather than contain the incident and wait for SWAT teams. According to the FBI, from 2000 to 2013, 18 incidents met the criteria for an active shooter incident in which a single law enforcement officer arriving on the scene was clearly documented engaging the perpetrators immediately. Of those 18 incidents, 13 were still in progress and in 12 of those incidents, the officer immediately neutralized the threat.^1,2

For EMS, the Aurora, CO, movie theater shootings was the sentinel event. Due to several issues in communication and coordination, such as misunderstandings between agencies regarding EMS entry and scene safety, fire and EMS assets were unable to gain access to the critically injured, resulting in many severely injured patients being transported by law enforcement. These gaps in communication left some responders without situational awareness of current circumstances and immediate needs.³

A review of the incident revealed that EMS and law enforcement must better coordinate and begin to practice and respond differently when these types of incidents occur. Citizens are demanding that law enforcement, fire and EMS find alternatives to rescue and improve outcomes for severely traumatized patients. The fact is that many of these critical trauma patients can be saved if EMS is aggressive in their approach and clearly understands and mitigates the risks as much as possible.

With the most recent Paris and San Bernardino incidents, EMS personnel must recognize another, higher-risk threat level than an active shooter. These types of attacks are coordinated and complex events that have been planned and perpetrated by terrorists whose intent is to kill as many citizens as possible, including response personnel, and to gain as much media attention as achievable for their cause. This is a game changer for EMS response. For these types of events, EMS agencies can no longer remain siloed with an insulated response from other community resources. Overall community response, particularly among all first responder agencies, is key to success in such atypical incidents.

The Traditional Response

Traditionally in EMS, when a violent incident of any type has occurred, personnel have staged their response at a safe distance. Since EMS providers are not armed or trained to confront a violent incident, this model should remain intact for all typical violent incidents. EMS should not confront a violent incident under normal circumstances without law enforcement clearing the scene. Once law enforcement has contained the threat, EMS providers can enter the scene and treat the injured. The types of incidents discussed here are different from a normal response and require a different approach.

The Response to Atypical Incidents

Response to an atypical incident must be planned and practiced before an actual incident occurs.⁴ Risk is involved in every EMS response; however, the response to an atypical event contains higher-risk elements, thus pre-planning and careful training must occur to lessen the risks faced by responders. EMS providers should clearly understand how they need to interact with other public safety entities and how this coordinated interaction can reduce their exposure to danger and improve patient outcomes. This is not to be taken lightly because in these types of incidents, the intent of terrorists is to cause as much death and destruction as possible, including public safety resources. The perpetrators have the advantage of surprise; however, public safety has the advantage of superior training, preplanning and the pooling of community resources to improve their approach.

As in active shooter events, law enforcement officers should directly engage the perpetrators upon arrival. The first four arriving law enforcement officers should eventually form an initial contact team that directly confronts the perpetrators, attempting to neutralize the threat and end the carnage. The fifth-arriving law enforcement officer should assume a position of incident command and begin organizing other arriving resources to adequately meet the needs of this very fluid incident. The incident commander should begin reporting the situation to dispatch, requesting additional resources as needed, collecting information about the current status of the incident, and forming additional initial contact teams of law enforcement officers and rescue task forces, consisting of arriving EMS, fire, and law enforcement as they arrive on the scene. This incident commander should utilize situational awareness to determine where initial contact teams and rescue task forces are needed to engage the enemy and evacuate victims.

The rescue task force is a team with a minimum of one law enforcement officer and one EMS and/or fire personnel. However, two law enforcement officers per team is optimal. The configuration may be larger, depending on the immediately available personnel and the needs at the incident. The mission of the rescue task force is to enter the warm zone behind the initial contact teams to begin hemorrhage control and rapid evacuation.⁵ Ideally, this would include tourniquets and blood clotting pressure bandages and any means of rapid evacuation of the injured. With limited personnel, particularly in the beginning stages of an incident, there may not be time to set up formal triage areas. In lieu of triage, patients should be moved to casualty collection points, where they can then be moved by additional personnel to the cold zone for rapid transport.

Going into warm and hot zones in an active and dangerous event with shooting and violent threats represents a new thought process for fire and EMS personnel.⁶ Fire may be familiar with operating in warm and hot zones of hazardous materials, but the actively violent threat is different and requires a different approach. EMS is very familiar with the golden hour of trauma; however, these severely injured patients lacking that hour need immediate evacuation and transport to survive. Injuries this catastrophic require that these patients be transported to a trauma center or surgery to save lives.

New Command Structures

While conventional incident command works in normal disaster situations, in an atypical incident there are not enough personnel nor is there enough time to set up this formal structure. Rapidly moving events, the possibility of multiple attack sites and limited resources, calls for a new approach to command structures. Each individual incident has an incident commander. However, with multiple, simultaneous incidents, coordination of available resources is key to meet the needs of each individual incident. The answer is Area Command.

Area Command is not a new concept, but it works in rapidly changing events with the potential for multiple sites of response and operations. Once there is recognition of a coordinated terrorist series of incidents or atypical incident, the first arriving supervisor should find a location that is safe and located appropriately far enough away from all incidents to establish an Area Command for coordination of community resources for all incidents. The Area Command may need to be moved if the threat shifts toward the command post. Commanders must always consider security at the Area Command since terrorists may plan secondary attacks on command posts once they are established. This includes setting up an Area Staging spot for initial response of resources to be directed as needed to each individual incident. Remember, the incident command at each scene and Area Command are abbreviated command structures to operate until a full incident command setup can be established, once enough personnel arrive on all scenes. The supervisor setting up Area Command can be from any response discipline.

All responding personnel should be ready, through cross training and temporary role exchange, to perform whatever duties may be needed for the incident. Obviously, only armed law enforcement can engage the perpetrators; law enforcement can treat victims while in the hot and warm zones if they are trained and appropriately equipped with tourniquets and pressure bandages. Fire and EMS could provide perimeter control or guard evidence if immediate medical or hazard control is not needed. Leading to a successful outcome is helped if all response personnel are willing to fill whatever roles need to be filled at the moment and shift with the changing stages of the event. All responders should be ready to function outside of their normal lane of activities and play the role that is immediately needed.

New Agency Requirements

For new approaches to succeed, critical thinking is required by leadership, with the use of resources that may not be utilized in a traditional response.

All public safety agencies and other potential resources should plan and train together for these types of incidents. Preplanning is one of the greatest advantages that public safety has in dealing appropriately with of these types of attacks. EMS should play a large role in bringing all community partners, regardless of local politics or jurisdictions, to the table for input and coordination.

Agency protocols should be coordinated to reflect the enhanced roles of the agency and its personnel responding in these types of incidents. Accordingly, mutual aid agreements should be in place between agencies and with surrounding neighboring jurisdictions before an incident occurs to meet these needs in extreme circumstances so that incident and area commanders are aware of available resources in a given situation.

Use of Unconventional Resources

Many times in an atypical event all resources will be strained and possibly unavailable. Responders must maintain situational awareness and understand what possible resources surround them to complete their mission.

Unconventional resources for extreme atypical incidents can include:

• Private businesses and entities;
• Public works personnel;
• Correctional personnel;
• National Guard and Civil Air Patrol;
• Private security guards.

Many of these unconventional resources may have surprising answers to the problems that present themselves.

Needed specialized equipment may also be in short supply. Thinking creatively may help alleviate equipment shortages. Use of barricades and dump trucks from public works can assist in establishing a perimeter. Use of plywood, tables, and chairs may be used to assist moving patients. When ambulances are in short supply, could other trucks or buses be used to move patients to hospitals with medical personnel on board? The answers will be different in each location and at each different incident and local and state law should be reviewed to determine if these resources can be utilized in a disaster situation.

EMS and Information Gathering

Law enforcement personnel are accustomed to gathering information to eventually develop an intelligence product to help guide response efforts and to feed into an investigation after an incident has concluded. EMS personnel should be aware that how the information they are presented may influence how the response unfolds or directs decision making. EMS personnel should understand that something they see at the scene or hear over the radio may be important information that could help mitigate the situation or shed light on how a response could be better coordinated. Responding personnel should clearly understand how and who to forward that information to if it seems to be important for the success of the incident. There should be a constant flow of information to the incident commanders to evaluate all information from all sources.

Creative Thinking and Risk-Based Decision Making

With these new challenges for EMS comes the need for critical thinking and decision making that reduces risk as must as possible for responders. Since the attackers have designed these incidents to overwhelm local resources, it is imperative that EMS personnel be aware of potential threats and be prepared to look for unconventional approaches to mitigate the situation.

Critical thinking involves being open-minded to alternatives, judging source credibility when information is received, asking clarifying questions, forming a hypothesis and drawing conclusions based on available information. Critical thinking is also being cautious about conclusions, understanding that conclusions can change based on new information. The good news is that EMS providers use critical thinking on everyday responses. Now they need to use their critical thinking skills in an expanded manner to encompass larger and more complex incidents. Critical thinking is not making uninformed, snap decisions; rather, it requires making the best decision quickly based on current information.

Everyone, every day makes risk-based decisions,⁷ but with the higher stakes in an atypical incident, risk-based decision making is a critical component of good outcomes. To make a risk-based decision, EMS personnel should ask these questions:

• What can go wrong?
• How likely is it that it will go wrong?
• Is the risk of the potential problem tolerable? What can be done to lessen the risk of the problem?

This process helps responders evaluate current information to make informed choices that lead to improved outcomes. This process involves a decision structure, risk assessment, risk management, and impact assessment that should lead to appropriate risk communication. Basically by asking the above questions, then applying the answers to the risk assessment, you can then make decisions to manage the risk and decide possible impacts of your decision. Once you have worked through this process, you then communicate what steps need to occur and then reassess the situation.⁸

It is important to understand that in the everyday job of EMS or in an atypical incident, there is inherent risk. Responding to emergencies and certainly to terrorist attacks, there is risk, but the idea of critical thinking and risk-based decision making is to make good, clear decisions and reduce that risk as much as possible.

Conclusion

An atypical incident, such as a terrorist attack, may prove to be the most challenging response to any EMS agency. However, with careful thought and planning, the ability to respond as a community-based team utilizing all community based resources can improve outcomes for injured patients and for responders.

The Department of Homeland Security has begun work on training courses related to atypical incidents. The Louisiana State University, National Center for Biomedical Research and Training, is in the process of developing courses for these types of attacks. Many courses exist for law enforcement on active shooter incidents and EMS personnel should seek this same type of training.

While there is risk responding to these incidents, planning a coordinated approach, critical thinking, risk-based decision making, unconventional approaches and the creative use of resources, can make the outcomes successful and save lives.

Glossary of Terms

Active Shooter Incident: The United States Department of Homeland Security defines the active shooter as “an individual actively engaged in killing or attempting to kill people in a confined and populated area; in most cases, active shooters use firearms(s) [sic] and there is no pattern or method to their selection of victims

Area Command: A command structure that is particularly beneficial to incidents that are typically not site specific, are not immediately identifiable, are geographically dispersed, and evolve over longer periods of time (e.g., public health emergencies, earthquakes, tornadoes, civil disturbances, terrorism).

Area Staging: Any area or place serving as a point of assembly or preparation on the way to a destination or multiple destinations allowing overall coordination of available resources.

Atypical EMS Incident: An incident that is outside of the normal response parameters of EMS agencies such as terrorist attacks or active shooter incidents that require a modified approach.

Casualty Collection Point: Casualty Collection Point (CCP) or Field Treatment Site is a location within a jurisdiction that is used for the assembly, triage (sorting), medical stabilization and subsequent evacuation of casualties. In the context of Atypical Incidents, the CCP in most circumstances may be used as an assembly point to move patients rapidly to waiting transport.

Critical Thinking: Critical thinking is the intellectually disciplined process of actively and skillfully conceptualizing, applying, analyzing, synthesizing, and/or evaluating information gathered from, or generated by, observation, experience, reflection, reasoning, or communication, as a guide to belief and action. In its exemplary form, it is based on universal intellectual values that transcend subject matter divisions: clarity, accuracy, precision, consistency, relevance, sound evidence, good reasons, depth, breadth, and fairness.

Initial Contact Teams: Consists of the first arriving law enforcement officers at an active shooter or terrorist incident that immediately and directly confronts and engages the perpetrators of the incident.

Rescue Task Force: The Rescue Task Force is an aggressive response to an active shooter incident that provides rapid medical treatment at the point of injury to those who have been injured. The RTF is a joint response between Police and Fire/EMS departments, but can be adapted to any agency large or small, rural or urban. It usually consists of at least one or more EMS/fire personnel to treat and evacuate patients and at least two law enforcement officers to protect the victims and EMS/fire personnel.

Risk-Based Decision Making: A process that organizes information about the possibility for one or more unwanted outcomes into a broad, orderly structure that helps decision makers make more informed management choices.

Situational Awareness: The perception of environmental elements with respect to time or space, the comprehension of their meaning, and the projection of their status after some variable has changed, such as time, or some other variable, such as a predetermined event and an understanding of the environment critical to decision-makers in complex, dynamic areas from aviation, air traffic control, ship navigation, power plant operations, military command and control, and emergency services such as EMS, fire-fighting and policing; to more ordinary but nevertheless complex tasks such as driving an automobile or riding a bicycle.

References

1. U.S. Department of Justice, Federal Bureau of Investigation. A study of active shooter incidents in the United States between 2000 and 2013. Sept. 16, 2013, Washington, D.C.

2. Blair JP, Nichols T, Burns D, Curnutt JR. 2013. Active Shooter Events and Response. Boca Raton, FL: CRC Press.

3. Johnson KH. Changing the paradigm: Implementation of combined law enforcement, fire, and emergency medical service (EMS) cross-disciplinary response to hostile events. Naval Postgraduate School, Monterey, California Thesis, 2014.

4. The Interagency Board. Integrating Law Enforcement, Fire, and Emergency Medical Services During Active Shooter/Hybrid Targeted Violence Incidents, August 2015.

5. Morrissey J. EMS response to active-shooter incidents. EMS World 40:7,42–48.

6. Macesker B, Myers JJ, Guthrie VH, Walker DA, Schoolcraft SG. Quick-reference Guide to Risk-based Decision Making (RBDM): A Step-by-step Example of the RBDM Process in the Field. Air University, 2002.

7. United States Coast Guard, U.S. Department of Homeland Security. Risk-Based Decision Making Guidelines. June 11, 2015. 

8. Ergenbright CE, Hubbard SK. Defeating the Active Shooter: Applying facility upgrades in order to mitigate the effects of active shooters in high occupancy facilities. Naval Postgraduate School, 2012, PhD diss., Monterey, CA.

Mac Kemp is deputy chief of clinical affairs at Leon County EMS in Tallahassee, FL. He has over 39 years of EMS experience and has worked for county, hospital and private EMS systems. He began his career at a funeral home that provided ambulance services. He currently holds a Master’s Degree in Health Education from Florida State University in Tallahassee, FL, and a Master’s Degree in Homeland Security from the United States Naval Postgraduate School, Center for Homeland Defense and Security in Monterey, CA. He also designs and teaches Homeland Security courses for the Louisiana State University, Center for Biomedical Research and Training.