Putting EMS and Fire Departments in the warm zone during an active shooter mass casualty incident (AS/MCI) is making headlines right now. It is in all of the popular EMS publications and making national news, there is just one problem; it is a bad idea.
EMS and Fire Departments do not belong in the warm zone of an AS/MCI*
There is no evidence EMS is needed in the warm zone.
There is no the data that EMS is needed in the warm zone.
What likely is needed at AS/MCI is not for EMS to play Police, but for the Police to play EMS and drive people to the hospital.
You may hear advocates of sending EMS and Fire Departments in to the warm zone say things about The Hartford Consensus and the Stop the Bleed campaign but these aren’t based on data or evidence or logic. I suspect part of the reason EMS and Fire Departments are embracing this notion is we buying in to our own hero mythos.
And I get it, it is cool to talk about tactical shit and say things like warm zone and feel like we are some type bad ass tactical operators. But we aren’t.
There are a few bits of rhetoric that are thrown out there that make it sound like there is no danger in an AS/MCI, or at the very least make it sound as those objecting to entering the warm zone of these types of scenes are being overly cautious. This information is stated as a matter of fact to make EMS and fire feel better about going in to the warm zone during an AS/MCI.
- “The shooters usually kill themselves before the cops show up.”
This is not true. The FBI states in “A Study of Active Shooter
Incidents in the United States Between 2000 and 2013” that 40% of the shooters usually kill themselves before police arrival and 56% of events are over before police arrival. That means 44% of the time the shooter still wants to kill people when law enforcement arrives on scene. This is about the same odds as a coin toss and using this fact to put unarmed, untrained responders in this situation is inappropriate.
- “The shooting is usually over in the first few minutes.”
The FBI states 70% of the shootings where a timeline could be ascertained were in fact over within five minutes. That still leaves roughly one in three times when it is not over upon law enforcement arrival. No untrained, unarmed person belongs in a situation where there is a 1 in 3 chance of an active shooter still being at large.
The whole notion that EMS needs to be in the warm zone is speculation based on faulty logic, bad science and an appeal to emotion. I know I am at risk of sounding like that one guy that is always talking about “sheeple” and telling you how jet fuel can’t melt steel beams, but stick with me here for a minute.
In 2013 following the Sandy Hook shootings The American College of Surgeons felt as though they needed to do something so they put out a three part paper called The Hartford Consensus. There are four parts of The Hartford Consensus, part III really gets in to hemorrhage control aspects during an AS/MCI and goes as far as advocating putting bleeding control kits with every AED in public. My buddy owns a company that sells tactical equipment and tourniquets and he references The Hartford Consensus rather frequently.
FEMA took The Hartford consensus at face value and put out a publication titled Fire/Emergency Medical Services Department Operational Considerations and Guide for Active Shooter and Mass Casualty Incidents.
“The Hartford Consensus identifies the importance of initial actions to control hemorrhage as a core requirement in response to AS/MCIs. Experience has shown that the number one cause of preventable death in victims of penetrating trauma is hemorrhage.”
Hemorrhage that is treatable by EMS is NOT the number one cause of preventable death in non-military AS/MCI. It is not even close to the number one cause, in fact it isn’t really a cause at all in these situation. I recently told my boss that we need to stock-pile tourniquets and hemostatic agents just in case there was an AS/MCI in our area. Luckily I got distracted and never purchased all of it, but I too was lead to believe that an abundance of C-A-T tourniquets and Celox would save the day. I was wrong.
In 2015 The George Washington University Department of Emergency Medicine did a study looking at the injuries from the AS/MCI in the USA. They looked at the autopsy reports from AS/MCI in the USA and looked for the presence of potentially survivable injures in the victims. They defined potentially survivable as “if pre-hospital care is provided within 10 minutes and trauma center care within 60 minutes of injury”
It is important to note that these were not just some random doctors. Dr. Smith voluntarily serves on the Executive Board of The Committee for Tactical Emergency Casualty Care. Dr. Sarani voluntarily serves on the Board of Directors of The Committee for Tactical Emergency Casualty Care (C-TECC).
After reviewing the autopsy reports they concluded that:
“7% of all the people shot in mass shootings who died might have had a possibly survivable injury and the majority of those (89%) had a chest or airway issue.”
They also stated:
“There were no deaths due to exsanguination from an extremity.”
While an airway issue or pnuemothorax is something EMS can fix, in a MCI it is likely that there will be triage. There is no listening to lungs sounds in a MCI, there is no BVM’ing in a MCI. It is head tilt, chin lift and move on.
So what is this drive to get EMS in the warm zone? There is not a demonstrated need for EMS to get in there and apply tourniquets and we likely won’t have the resources to treat these people in the warm zone. If you want to talk about a campaign of “Drag Them to A Surgeon Now! The Fastest Way Possible…Yes, Even In Your Cop Car!!! GO!!!!” I can get behind that idea.
A Few Real Life Examples
The Aurora Theater AS/MCI
The Aurora Theater shooting in Denver was one of the biggest AS/MCI in the USA. It was a solitary shooter and within six minutes of the first 911 call the shooter was in police custody. This is the exact scenario those advocating for EMS to go in the warm zone talk about. EMS was not needed in the warm zone, what was needed was for EMS to do their primary job of taking people to the hospital and there was some room for improvement in regards to that.
The after action report states the following: “There were not enough ambulances on scene early enough to transport all the red patients, even if they had not been delayed in getting to the patients.”
Triage was performed by one member of the Aurora PD Swat team who was also a paramedic. Pulling directly from the Aurora Century 16 Theater Shooting After Action Report for the City of Aurora (page 45):
The reliance on the APD (Aurora Police Department) to conduct initial triage inside the theater raised some questions:
Did having APD personnel perform triage slow any other police functions?
Would a larger number of paramedics have improved initial triage?
Were any patients misclassified?
The answers to all of these questions is no.
Nowhere in the after action report is there any mention of a need for sending in EMS to the warm zone, however this is in there:
“Aurora Police Department should consider expanding the EMS scope of practice for police officers, especially for gunshot wounds.”
Dallas, Texas AS/MCI
Lets look at a case where EMS or fire went to the warm zone of an AS/MCI. On July 7th, 2016 Micah Johnson opened fire in Dallas, Texas. What happens when we put untrained people on scene and tell them to go in to the warm zone?
“They were being told by police to stay back, but they knew there was a Dallas downed officer ahead of them, and so they drove into the hot zone and were taking fire to get that officer into the ambulance”
The police told them to stay back…..but they went in anyway. Just let that sink in for a minute.
Are they Heroes? Reckless? A bit of both? I can’t tell you how I would react in the same situation without being there. Their intentions were good but when untrained firefighters do not listen to the police and go charging in to the hot zone it is not a huge leap of faith to say this could have played out much differently.
These guys were actively shot at. This could have easily ended up with wounded cops and a truck full of dead fire fighters.
“I had guys who got back to the station who said they had bullets whizzing by their heads,” – Cristian Hinojosa, the president of the Latino Firefighters Association.
This is why we need to take a step back here and slow down. We cannot simply send in EMS and Fire Departments in to the warm zone with little to no training and expect things to go smoothly.
There may be a time and place for EMS to enter a building with an active shooter still at large but making blanket statements about how EMS needs to be in the warm zone is wrong. We risk creating, or may have already created an argumentum ad populum, where people employ circular logic to answer the question of why does EMS go in the warm zone with an answer of, that is what we do.
It is a case by case basis and the last thing EMS needs to do is embrace any more danger in the workplace. The amount of risk one should take should be an individual decision, not a blanket policy based on bad science and hyperbole.
EMS is already a dangerous job. We routinely make the top ten lists of most fatalities in the workforce. Do we need to embrace a cavalier attitude towards adding more danger to our jobs?
*For clarification I am not talking about tactical medics that are members of teams and regularly train with teams like SWAT. I am talking about the regular medics like myself who take old ladies with hip fractures to the hospital, going in while there is still an active shooter in the building.