Five Questions With: Chris Kotecki, LSU NCBRT/ACE Instructor

With no foreseeable decline in active shooter events, first responders must be diligent in developing their response protocols to keep up with evolving threats, aiming to save as many lives as possible while also protecting their own. The Active Threat Integrated Response Course, hosted by Louisiana State University’s National Center for Biomedical Research and Training/Academy of Counter-Terrorist Education (LSU NCBRT/ACE), trains responders to develop the right skillsets to accomplish those goals. EMS World attended one of these courses in New Jersey and spoke with one of the LSU instructors, Chris Kotecki, to discuss how these courses better prepare first responders in the event their community is impacted by a mass shooting.

EMS World: As perpetrators of mass casualty incidents evolve their tactics—from shootings to van attacks to hazmat incidents—how is medical care evolving with them?

Chris Kotecki: Well, the priorities have changed. Back in the day, the golden hour was the key concept in blunt trauma cases, like in motor vehicle crashes, doing head-to-toe patient assessments, looking for fractures and other injuries. Today, with a segment of our population wanting to inflict great bodily harm and death using firearms in mass shootings and using new tactics like vehicles as weapons, if you stay with the typical head-to-toe survey, you're going to miss the major bleeds caused by penetrating wounds and people can bleed out in front of you within as little as two minutes. 

Things are changing in the way we’re doing our assessments based on the tactics that the perpetrators are using. What we're asking the responders to do in this course is to actually reverse the process. So instead of doing a head-to-toe survey, you're doing a boot-to-belt assessment. We start with the lower extremities and move our way up, checking the anterior portions of the lower extremities, rolling them over to assess the posterior portion of the lower extremities, then going to the neck, followed by the arms, chest, back and then the head area. The rationale behind this concept is military research shows that people are still dying today from extremity exsanguination from gunshot wounds. This boot-to-belt assessment helps quickly identify and treat bleeding from these major blood vessels.

In these events, there are two time clocks. One is: the longer the shooter keeps going, the more people they’re going to shoot and possibly kill. The other is: the longer it takes to get to the victims, the greater the potential of more victims. Now, the goal is to determine how we can get paramedics and EMTs to our victims, plug the holes, stop the bleeding, and get them to a hospital in a reasonable amount of time.

Now that EMS providers are operating more frequently in the warm zone, should they be expected to employ ballistic gear during these events? 

In the perfect world, we would rather prefer everybody going into these situations to wear ballistic gear, because the warm zone can go hot. If we haven't checked an entire building, the shooter could pop out from another room. Could there be a second shooter? Absolutely. There are just so many things going on. Everyone on the rescue task force should have a vest and helmet so they can safely carry gear to help transport, move, and render aid for the victims involved. That's not just our opinion. Everybody who's involved in this course would say they should have ballistic gear. While different communities have limited resources, i.e. personal protective equipment (ballistic gear) for the rescue task force, they can still rely on the law enforcement component to provide protection and security to the rescue task force.

Picture your daughter, your son, your wife, your family in that event and somebody on the outside saying, ‘Yeah, I'm not going in.’ If there was an active shooting event at a school and your kids were there, you would probably be beating down the door to go get them. Well, if you’re a first responder, you're that person saving somebody else's kid. Yes, people [in EMS] absolutely didn't sign up for this, but times are changing. Statistics and research show we have a definite impact through our actions if we can access patients relatively quickly within the first couple of minutes to save lives.

How do police, fire and EMS agencies feel about interagency training in these courses?

You think that there would be a lot more resistance to it, but everybody's looking at this knowing we have to evolve and start working as a team. We have to integrate if we're going to have an impact and people are going to survive. Just like we learn from the bad guys’ tactics, they learn from us. They learned that tourniquets work really well for gunshot wounds, so now they're driving trucks through crowds of people and they’re driving for distance. Now you've got multiple people with different injuries that you have to take care of over a greater distance instead of in one room or building. They're learning just like we do, and it's become this cat and mouse game of asking, ‘How do I keep ahead of the curve? I’ve got to evolve.’

Teaching these courses, I’ve watched people go from, ‘Yeah, I don't know if I like this concept’ to ‘Wow, we can apply this and actually see that integration of everybody working together successfully.’ Everything has been “Our Lane” in the first responder community. When law enforcement trains, it's just law enforcement. When fire trains, it’s just fire, and when EMS trains, it’s just EMS. We can't do that now. We all have to train together. Big cities, small villages, townships, wherever. We have to understand what the goal is. It’s our job to make sure everybody goes home at the end of the day.

We’re not forcing a policy or procedure down their throat. We're saying, ‘Here's a best practice that's now becoming realized throughout the United States. For the next three days, just have an open mind and see if there are any parts you can take away from this.’ Based on the size of your department, you might not be able to do everything from the course. Just take little pieces away and apply them. Start doing interagency training. If your police department is doing tourniquet training, actually get the EMS crew to do the training. Somebody in law enforcement isn’t going to know the anatomy and physiology behind what that tourniquet is going to do and where major arteries are located. We hear success stories months, days or even hours after taking a class. People say they applied some of the skills that they learned in these courses and had an impact on saving a life.
 

How do you see participants’ abilities develop throughout the course?

They progress wonderfully. I'll be honest, the first scenario is usually a cluster and they struggle. There's often a big delay from the time they get their first patient to an ambulance and actually have them transported away from the scene. The scenario often lasts way too long and there are lots of things where they could improve on. That's the crawl phase, but by the time they get to the fourth scenario, the instructors are out of it. The participants figure out what their roles are, how to communicate, and how they fit into the command structure. They've learned from their mistakes, reached all the benchmarks, and have gotten their patients out in a very timely fashion. They've gotten the scene controlled and we pretty much don't have to say a word.

What's so impressive is some of them will come in with an attitude of ‘This isn't for me.’ But usually by the end of the third day, which is all scenario-based, there are a lot of questions for the instructors like, ‘How can we get more training? How can we progress from here? What are the next things we need to do?’ Or they simply tell us, ‘Hey, you enlightened me. My eyes are open. I didn't realize we had this significant impact on saving somebody's life.’
 

What can providers do to improve their MCI response training?

Keep your mind open to the new changes that are coming. There is scientific research that’s directing what we're doing and why we're doing it. We’re looking at military studies being done on treating soldiers who were killed or shot in the line of duty and applying those principles to the civilian world. In the old days, we thought if you put a tourniquet on someone, they were going to lose a limb. What do they mean now? Tourniquets are our first line of treatment when taking care of major bleeding. They save lives and they save your limb in some cases if they're applied properly. So, the biggest thing you can do is to just keep an open mind. You are going to have a huge impact on saving somebody's life one day.

Chris Kotecki is a retired public safety officer from the Kalamazoo (Mich.) Department of Public Safety, where he served as a law enforcement officer, firefighter and paramedic. He is also a registered nurse and now works as an SME and instructor coordinator for LSU NCBRT/ACE.