By Julie Downey and Charles Kean, IPSA RTF Committee Members
By design, active shooter hostile events or mass casualty incidents are used to cause wounding and death on a large scale. As public safety agencies work toward appropriate responses to ASHE/MCIs, whether in the form of a shooters, bombers or any other hostile means, the MCI aspect of the response plan is often lacking. Law enforcement must continue working with their public safety partners to gain rapid access to an unstable and dynamic situation, and the medical community also needs to be included in the response model.
The rescue task force concept of providing immediate medical care to the injured during an ASHE/MCI is gaining traction. As the incidence of ASHE/MCIs rise in U.S., the evidence of RTFs saving lives is also growing. While many jurisdictions are implementing RTFs, as we saw in the 2017 Las Vegas shooting, several agencies have not adopted the concept.
This article examines two jurisdictions in the United States and highlight the common goals, problems and some unique situations present in various ASHE/MCI response models.
Springfield is the capital of Illinois and is in Sangamon County. In a city of 118,000 people and a county of 245,000, there are two different level-one trauma centers. With over 20 fire departments and EMS providers along with 25 law enforcement agencies, getting all of them on the same page is difficult. Complicating the ability to synchronize various agencies is the composition of the departments. Three private ALS EMS agencies provide the bulk of the transport in Sangamon County, and law enforcement agencies range from a two-member department to a 245-member agency.
In Springfield, as the planning and training for implementation of the RTF concept has evolved, casualty triage has taken a more prominent position in the overall concept of operations.
In the Springfield program, the contact team is tasked with neutralizing the threat. This is common in most RTF plans. The contact team is directed to notify incident command about the location of victims, and if possible, the number and condition of the injured.
The first RTF to enter the crisis site and begin the treatment and evacuation of the casualties has a rather simple triage method, dead or not dead. As the RTF moves through the area, patients are treated and marked for evacuation, or if capable of movement, directed to exit the site through the same path the RTF and contact team entered. While some may argue it is dismissive to triage with the categories being dead or not dead, the purpose for the initial RTF is to quickly assess patients with easily correctable life threats and then move on to the next patient.
After this is completed, then additional RTFs are tasked to evacuate casualties and re-evaluate patients using the more traditional START methodology. This includes reassessing patients marked as dead, unless there are obvious non-survivable injuries. In the revised MCI plans, the four-category START system is fully implemented at the warm-zone and cold-zone interface.
Working with hospitals
MCI plans need to include first responders (law enforcement, fire/EMS and 911 telecommunicators) and local hospitals. Many hospitals are unprepared, and if a MCI comes to their facility or if there is a potential for violence at the medical facility, they will simply call law enforcement to secure the facility.
Often the reality is that during an ASHE/MCI, law enforcement will be deployed to the crisis site. The agencies that are adjacent to the stricken jurisdiction will be involved in assisting their sister agency with response on site. In short, law enforcement resources will be scarce when it comes to the physical security of medical facilities.
Several recent ASHE/MCIs have occurred when key hospital administrators and management personnel were not on shift. Therefore, hospital administrators and managers need to have policies in place that allow the movement of less critical patients from critical care beds to waiting rooms or treatment by physician extenders such as nurse practitioners and physician’s assistants. Along with written and legally reviewed policies, charge nurses and unit managers need to be trained and empowered to make those treatment decisions, in consultation with the emergency department, attending physicians and where applicable, trauma surgeons.
Each of the level-one trauma centers in Springfield operates its own EMS system. To the benefit of the community, the EMS protocols are nearly identical which aids in reducing confusion in providing pre-hospital care. The MCI protocols for both systems are the same. They use the START triage system. However, there are some limitations with solely relying on the START system. For example, while it is designed for MCI situations, it does not address active threat environments. In the high stress and dynamic environment of an active threat, MCI is often the most overlooked aspect is the triaging and evaluating casualties.
Hospitals and patient transport
MCI planning must consider patient transport. During crisis, patients are arriving at medical treatment facilities by conventional EMS transport, law enforcement transport and/or self-evacuation. This model, while difficult to control during chaos, may create an unintended reverse triage. Patients that are capable of self-evacuation often are not severely injured, and they will likely arrive ahead of the patients who are in dire need of medical interventions, especially resuscitation and surgical intervention.
During an MCI and patients are being transported, there is a misconception that law enforcement will be available to secure medical facilities. There may also be a perception that the hospital’s internal security will be able and capable of controlling access to the hospitals, especially the emergency department. This is not typically the reality.
Training immediate responders
Another area for improvement is community resilience. In central Illinois, the HSHS St. John’s Hospital Trauma Team is using outreach education to teach Stop the Bleed to local fire and law enforcement agencies. The next goal is to implement a program like Davie, Florida and get bleeding control kits in the community with AEDs.
Davie is a highly populated town located in Broward County, Florida. Most agencies agree the public needs to get involved in rendering immediate care for someone that is severely bleeding. In October 2015, the Davie Fire Rescue was recognized at the White House/Department of Homeland Security for their innovation in developing Severe Bleeding Kits and distributing the kits to all their AEDs. In addition, they incorporated the severe bleeding training into all their CPR/AED classes. They have renamed the program to coincide with the DHS program – Stop the Bleed.
Early MCI management issues
Since the early 2000’s, several issues were identified regarding MCI management in Broward County. The biggest issue was that each of the 20 fire-rescue agencies in Broward County had adopted their own MCI plan. When mutual aid was provided from neighboring departments, as is frequently seen during MCIs, this led to multiple levels of confusion. The region identified the need to correct this problem with all agencies in Broward County agreeing to a single MCI protocol that consisted of common terminology, triage and tagging methods. This has greatly improved MCI management, which expanded state-wide.
In early 2004, Florida’s EMS Advisory Council approved and recommended a MCI procedure and a state-wide MCI triage tag. Funding was secured through DHS grants for the state to supply all ALS agencies with MCI equipment. This included a common field operation guide, field unit bags with personal triage fanny packs, MCI tags, colored tarps, identification vests and MCI trailers.
MCI management achieved, but RTF issues surface
To ensure all first responders were using the same guidelines for MCI management, the procedure was placed in the Florida Fire Field Operations Guidebook. This FFOG, funded by the State Fire Marshall’s Office, was provided to every first responder vehicle (law enforcement, fire and EMS) within the state.
State-wide strides were made to prepare all first responders for MCI management, but equipment and procedures are not enough. There remains an on-going need to continually train, utilize and refine the procedures to ensure a constant position of readiness. Unfortunately, what was encountered 20 years ago with MCI management in Florida, is now occurring with the fire-rescue response to an ASHE/MCI. Law enforcement and fire-rescue agencies across the county and state are now developing their own sets of procedures and terminology.
The RTF concept is gaining in acceptance, but it is still not widely adopted. Some agencies fear that their personnel may get injured. Other agencies debate whether RTF personnel need to have full ballistic protection. Davie Fire Rescue has trained all personnel in RTF with classroom training followed by walk-through exercises and several full-scale exercises. The biggest obstacle we face is creating a true unified command. As we train more with law enforcement, we will see improvements.
Most fire-rescue agencies see the need to change our response to an ASHE/MCI. They see the need to get-in quicker to stop the dying, but there is no consensus on what this model looks like. Fortunately, there are several excellent resources now available through the International Public Safety Association, and even the National Fire Protection Association has a committee working on Active Shooter response (NFPA 3000).
As active threats continue to evolve, first responders, medical treatment facilities, community leaders and civilians must evolve their training and response.
International Public Safety Association’s Rescue Task Force Best Practices Guide
International Public Safety Association’s InfoBrief: Stop the Bleed
International Public Safety Association’s Position Statement supporting Stop the Bleed