EMS in the Warm Zone: A Bad Idea Based on Bad Science.

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.

LA times active shooter
Source

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.

tactical ems
“As long as you don’t get shot in the face, neck, upper back, side, abdomen or pelvis you’ll be fine. No, you can’t have a gun. “

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?

dallas truck
Where is the line between bravery and reckless?

“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.

Advertisements

48 thoughts on “EMS in the Warm Zone: A Bad Idea Based on Bad Science.

  1. I whole-heartedly disagree with “police should play EMS and drive people to the hospital”. I’m offended that you think of our profession as “driving people to the hospital”. The evidence doesn’t support taking LEO off the scene of an assumed active event to transport injured civilians. LEO’s job is to secure the scene and neutralize the threat. It’s not bravado, just common sense for EMS to transport patients from a secure CCP despite the scene not being safe by NREMT standards. We are public servants and if you aren’t willing to accept risk in order to save a life, you should find another career.

    If you honestly believe prehospital assessment and treatment of trauma patients is simply a “ride to the hospital” you are simply a taxi driver and you are the type of clinician I tell my students to avoid.

    I admire your research and acceptance of EBM but, in this case, the evidence can’t be accepted as best practice without discussing the many other variables on these extremely dynamic situations.

    Like

    1. Please reference the aurora shooting after action report in the blog.

      There is data that points to in GSW ambulance tx/transport is no better than a ride in a cop car.

      Liked by 1 person

      1. I disagree with a ride in a cop car Iano different than a ride in an ambulance with a GSW.

        As a medic that has treated and transported many gunshot wounds from police scenes, I can say that the officers, myself, and the patients had a higher likelihood of a positive outcome with the patient in my care.

        I’m not trying to take away from the officers in any way, but what I do is not what they do. With my scope and my protocols, I can treat very agressively as I need to and deliver to definitive care. No matter where I am in my system, I’m no more than 10-15 minutes from a trauma center and I more than 13 minutes from having a helicopter on the ground if needed.

        But, as all ideas that exist, the idea of moving to the war zone is not completely a bad idea. It’s going to take a lot of coordination on all sides, a lot of communication, and significant training. But in the end,if we as public safety can adds capability that leads to faster and more definitive treatment to those that need it when and where they need it, then I think we owe it to the public and ourselves to find a way.

        I public safety, we are all really good at two things. We thrive and are the masters of chaos. And we are professional paid problem solvers.

        I think we can solve this one.

        Like

    2. There have been several studies now that show higher survival rates among shooting victims when transported by police car or taxi, than when transported by ambulance.

      Liked by 1 person

      1. Do those studies compare the time between gunshot and arrival of PD and subsequent transport by PD vs arrival of EMS and subsequent transport by EMS? In every case of the numerous case studies I’ve read, PD times were shorter than EMS times because PD was on scene first and transported prior to EMS arrival on scene or prior to EMS making patient contact. If an uber driver arrived on scene first and transported, I am confident that über’s numbers would also be higher. It’s about shortening the time to surgical intervention. Quicker access by EMS would reflect better numbers for EMS. With the added benefit of (theoretically) trained providers and equipment.

        Had EMS been able to “load and go” at Aurora, we wouldn’t be having this conversation.

        Like

      2. Does the study mention anything about an ISS score or some other quantifiable and objective way of determining if these patients were critical or could have possibly walked themselves to the hospital?
        Reference your study. I’d like to read it.

        Like

      3. No question, rapid transport–cop car or ambulance. The facts are published. I’ve been in the field for twenty years–I even had my own school shooting to respond to as the incident commander. I appreciate your perspective as a practitioner of EMS, but I’d respectfully disagree with your assessment. We do an awful lot to stabilize patients, but there’s a limit to what we can do.

        Very respectfully

        Like

    3. Amen to that.!
      There are three services for a reason.
      Make cops be cops. Firemen be firemen. Let EMS personnel do their jobs.
      There is no mention of faulty triage in the after action report because from my experience it is never in there. It happens all the time. The police were transporting people to the hospital that were dead by the time they got to the hospital. Wasting valuable resources for other victims. The problem is EMS is constantly set up for failure and then gets blamed for it. What do you expect? Hire more personnel, put more ambulances on the road. Let us do our jobs!! Do one job well not several jobs 1/2 way. How can a police officer protect the scene or make it safe when he or she is distracted by doing something else that’s not their primary job and they don’t do it all the time? I would never try to enter a building to put out a fire or try to arrest someone, so why are they expected to do our jobs? There is a THREE tiered system for a reason it works. Let it work. It’s not broken stop messing with it. I get we are all in it together, so let’s do that. Team effort. It will work! Already proven! Thank you to all of the emergency service personnel for their service. Keep safe!

      Liked by 1 person

      1. IMHO the tactical cops need tactical medics with EMS following up as close as is achievable. If you are going to put EMS into the warm zone then they need training and appropriate PPE.

        Like

    4. I don’t think the author’s comments were an attempt to lessen what we do as professionals, however, rapid transport to definitive care is supported by empirical evidence.

      Like

  2. It is trying to use army and marine medical principles, well ignoring that every medic or corpmen’s first job is the neutralize the threat, because the most important thing is to ensure there are no more casualties are made, or worsened.

    You can not do this without armed medical providers. Army medics do not provide care when they have bad Guys to shoot.

    Like

  3. Additionally, we know that the published training doctrine of ISIL, responsible for a majority o mass shootings in the last few years, is to have at least two shooters, with one who’s primary job is to serve as over watch & protect the main shooter.

    It is trying to use army and marine medical principles, well ignoring that every medic or corpmen’s first job is the neutralize the threat, because the most important thing is to ensure there are no more casualties are made, or worsened.

    You can not do this without armed medical providers. Army medics do not provide care when they have bad Guys to shoot.

    Like

  4. A difficult situation to be in, but nonetheless very real. We respond to such situations but only enter when given the all clear by security services on scene. Dead medics are no good to anyone. Guns for medics are a touchy subject the world over, however in our country it is becoming a necessity due to medics being deliberately targeted at scenes and ambulances being hijacked. Good old South Africa where anything goes.

    Like

  5. EMS Response to active shooter scenarios is real and needed, I have followed a lot of the discussions about this and most people tend to think that we are advocating for EMS to rush into the “hot” zone.
    We can not wait for a scene to be “safe” if there are multiple casualties. We must have a coordinated, well thought response and yes it means we must go in. To say that police must start transporting casualties is a joke and should never happen.

    Once the shooter / shooters are down coordinated entry with LEO providing cover can be made. If shooter / shooters are “cornered” and no way out for them EMS again can make entry with LEO cover.

    Like with all things we must train and work together to achieve the best outcome.

    Like

    1. No shooter is ever cornered, people can always move, and the threat of radio or other remotely detonated secondary devices is not only real, but extremely likely.

      The shooters needs to be killed, and everyone arriving on scene should be ensuring that happens. Outside of a tourniquet there is no other recommended treatment well a threat exists.

      As always, Any & all responders must be armed, and no one can be evacuated until large numbers of responders are on scene. Military studies show similar results to RIT studies from the fire service, it takes on average 8 personal to Evac a non walking causality. Security must be maintained until out of the engagement zone, (which is not gong to happen until several minutes after transport) because again, all serious studies show that there is more likely than not going to be secondary threats/actors, who maybe acting as “victims” or bystanders.

      Additional, peer reviewed (as well as!standard military Pratice during OIF), studies have shown that Evac by police can save lives. In urban areas trauma centers are close.

      Every cop should know how to apply basic trauma care – T-kit, combat gauze, ace wrap, but that is just common sense.

      Any major incident in any part of the country is going to vastly out strip the ability of EMS to have the transport resources to handle the call.

      Like

      1. “Outside of a tourniquet there is no other recommended treatment well a threat exists.”

        Not true. Needle chest decompression and occlusive chest seals for tension pneumo/he mothorax and penetrating chest trauma may also be indicated and beneficial. “Threat exists”: are you talking hot zone/rounds coming downrange threat, or that the threat is somewhere in the nearby area? As a former Tac Medic with a dignitary protection unit, TECC Instructor for both LE and Fire/Rescue/EMS, and still working Medic covering a large diverse area with high density urban infrastructure to rural and everything in between, our entire department (1,500 field operating personnel) drill regularly with law enforcement. From when we revised our unified LE/FR-EMS manuals for active/hostile threat engagement and began training together, we’ve seen a tremendous change in culture. Once everyone got on the same page and we had the buy in from the line unit personnel up to the senior brass, we’ve not only run realistic training scenarios efficiently, quickly, and successfully, but we’ve employed the system on actual incidents successfully as well.

        Our lessons learned include:
        – really research and develop a program (which includes education, equipment, and regular training)
        – develop flexibility to scale up/down and adapt dynamically to each situation.
        – research and test equipment and techniques thoroughly under realistic scenario conditions before investing in them
        – cross-train LE and FR-EMS, and train together regularly, and do so at all scales (from several single units and officers responding to midsized response to a large scale unified event)
        – make scenarios realistic and as diverse as the types of responses and locations you may encounter in your area.
        – strong emphasis on developing solid communications between agencies and responders, with language everyone is familiar with and will default to when the SHTF and everyone gets tunnel vision.
        – develop the program with cost in mind. The less expensive and more “cost-neutral” the better the buy in, investment in it, and ability to maintain it.

        Much of the concern/criticism of EMS working in the warm zone can be addressed with these approaches.

        Like

      2. HMRT: you cherry picked one sentence, ignored everything around it, and spent another 5 saying how awesome the program you wrote was, without any actual facts, just a bunch of buzzwords.

        To have a warm zone, you have to know, exactly, where the hot zone is, and have something which stops bullets between you and the hot zone. Good luck finding that in American Constructon outside of sky scrapers. Thus there are only two treatments. Move to engage.
        T-kit.

        Past that, security must be established, and an extremely short list of interventions can occur, if you do get cover. A good commercial chest deal (not some BS plastic wrap; or asherman that isn’t going to work), combat gauze / packing / compression dressing. Nasal airways /’crics. If incident is allowed to drag on, chert decompression.

        I’d also add pain management, because IN fentanyl is a pretty fast admin.

        But Evac? No one evacs from a hot zone, or even a warm zone, in an ambulance, because you don’t bring in specialized medical resources (ambulances) into a threat area. The marines don’t. The army doesn’t. (Exception – Israel, but their ambulance has a 120mm main Cannon).

        Medical care is provided by armed personal attached to said military unit, and primaily every soldier themselves. 1 EMT for 40 soldiers.

        You secure the situation and destroy the threat, or you break contact – which in a domestic operation would not be an option.

        Like

  6. As a tactical medic operator and national instructor in that dicipline, I will say that I agree with you…. Partially. Moving in a warm/hot zone takes training and a lot of it. It is a perishable skill as is any technical skill. If not done right you can risk everyone’s life, SWAT, LEO, citizens, and yours.

    The interesting thing with the ‘study’ that was published about wound data from active threats is that it is limited and incomplete. Even Doc Smith does not have access to the medical data because it is either classified or non existent.

    The groovy thing is there is more than one way to mitigate an active threat response. Unfortunately a lot do not know about them. Escorted Warm Zone (RTF) , Island, Cooridore, Complex, and LEO Rescue to name a few.

    If you are going to pick at RTF and how bad it is, please give folks a resolution. While I do not agree with the RTF at least some agencies have the testicular fortitude to o something.

    Like

    1. I think one problem you are overlooking is the vast differences in EMS not only nationwide but within a state. I know the Sandy Hook area personally. It is a small town served byy a contract paramedic who is shared by three towns. EMS/Transport is an all volunteer group made up during the day of mostly stay at home people. The fire department is all volunteer. The town cannot support a fulltime paid resource. The town next to them has an ambulance staffed mostly by retirees and senior citizens. Aurora is a well funded good sized city/town

      Like

  7. Maybe a better question would be what about training more cops and security services for hemorrages and airways management and let them do it in the warm zone

    I think EMS don’t have their place in AS/MCI… I’m steel a student in paramedic school but I’m sure that without tactical training we are just more targate and not anymore “savers” just keep in mind that a dead medic is no more usefull..

    Like

  8. As an EMT, I was trained in Tactical Medicine at Fort Dix in AUG93 with the FBI and later went on to become Deputy Chief of Police in a City outside of Dallas.

    I can appreciate the author’s intent and find most of his points hard to argue with; I will however, state that this subject is not being debated in the correct venue.

    EMS and Law Enforcement will forever be at odds on certain subjects. Different mission statements, different parochial and institutional interests, different agendas, different occupational mind-sets that TACEMS training cannot overcome.

    Back in 1993 we argued BLS vs ALS in tactical law enforcement environments. Scoop and Move won that argument then, I can’t rationalize why its a point of contention twenty-three years later.

    There is not and will never be a one-size fits all plan, policy or procedure for an MCI and probably never should be. So that decision can’t be made here.

    EMS staging for an event should always be the sole decision of the On-Scene, TACTICAL Commander. Not Patrol, Not Negotiators and Not EMS.

    There are a miriad of variables that should be hashed-out with police before these events even occur. Tactical Teams all over this country perform Tactical Site Surveys and will study floorplans, walk through and photograph major buildings and venues in the event an incident materializes at that address. Obviously, EMS should have been included in the debriefings and planning that occured after the TSS.

    If any metropolitan EMS agency (Fire Dept. or otherwise) does not attend these meetings or simply doesn’t have the SWAT/Tactical Unit CO’s ear to discuss this, Someone needs to change it, NOW!

    I am amazed that any EMS agency in this country has not sat down with the City Attorney or County Commissioner’s to draw up a Memorandum of Understanding with a local armored car company to utilize one of their vehicles if necessary to handle patient/officer extractions (modifications to the vehicle like holes in the floor for a stretcher lock assembly paid for by the local government) and an agreement with law enforcement that THEY will, in the absence of qualified TACMED personnel, be the ones to exit the vehicle to retrieve the injured.

    Decisions on EMS Staging cannot be made by any one part of the Public Safety “Triad”. If law enforcement does it alone, we will see a repeat of Waco. If EMS does it alone, it will likely be “in the way” or will not function with the efficacy it must.

    Like

  9. From my experience. Yhe moet valuable person on a MCI is EMS. Not the victim. You are. If EMS got wounded. Who is taking care of you? Frist rule of EMS is safety second. Second Rule? Safety!!! Third Rule? Start thinking. Are you safe. Are the People around you safe? Then do you’re thing. Do the thing you do best. Improvise. If they have to go in a pick-up truck. Do so. Decide who has to go that way. That is why you are there.
    Stay safe friends

    Like

  10. For all the snow flakes that are offended by the suggestion that GSW patients should be transported by police…http://articles.philly.com/2014-01-09/news/45995105_1_gunshot-victims-police-car-shooting-victims

    We are working also currently working on https://medicine.temple.edu/departments-centers/clinical-departments/surgery/research-programs/philadelphia-immediate-transport

    Because it is believed that at least in the urban environment, less care is better than more in the prehospital setting.

    It probably doesn’t matter who provides care under fire, tactical field care, or even transport. We need to stop pretending that victims of penetrating trauma truly need an ambulance as anything more than a means of getting to a surgeon.

    In settings of active shooter/dynamic scenarios, or whatever we are calling them this week, the hard truth is that many patients will survive no matter what we do, while others will die no matter what we do. There are very few that only survive because of what we do.

    Like

  11. One or two victims…sure throw them in a squad and get them to a hospital. 20-30 victims needing IMMEDIATE transport? Where do you think all these cops and cars (with no other duties other than patient transport) are going to come from?

    Like

  12. What we need is a system where personnel not actively engaged in the event can enter the “warm zone”. Evacuate the wounded to an emergency treatment/triage area and from there have personnel and vehicles start transporting the wounded based on the resources available and the severity of the injuries. Because once you start getting into the double digits there just isn’t going to be enough bodies/cars to transport them all at once.

    We have a surgeon in our County who is “on call” in a stocked response vehicle available to respond to emergencies such as this and run that triage area. Having resources like him more commonly available should be on our national “to do ” list…..

    Like

  13. There were some good points brought up here but in the end the author’s burden of proof was an opinion. Some of his statistics were cherry picked or represented differently than the common interpretation (I’m not saying misrepresented). While I agree that the likelihood of EMS needing to enter the warm zone is remote the author’s minimization of the value of treating a small percentage of victims appears to be cold and depersonalized to the responders who actually will have to experience dealing with these deaths in a mass casualty incident.

    Regardless the author certainly brings up valid debate.

    Like

  14. In my rural area, there are limited LEO resources. There will be no LEO available to escort EMS into the warm zone. Even when there is an LEO present, if the warm zone becomes a hot zone, the LEO is going to move toward the threat and leave the EMS team unguarded. Or there will me multiple/covert attackers. Or the LEO will become a casualty. EMS in the warm zone should be equipped with self defense tools like firearms, or have their own dedicated defenders. But on a more global view, EMS is more likely to be assaulted or killed on a routine run. Just google “EMT shot” to get a multitude of real events. I advocate for EMS providers to be allowed (not required) to be trained and able to carry a concealed firearm (as well as less lethal defense tools) at all times

    Like

  15. you are correct in rejecting UNtrained personnel working in a warm zone. You are INcorrect in totally rejecting the idea of the disciplines working together in a potentially active situation.I believe you would have a much deeper understanding of the topic if you actually took part in some training. I did, and it was both eye-opening and empowering.

    ALL the personnel involved in a warm zone rescue MUST be trained IN — THAT — TYPE — OF — SCENE. (I am capitalising because Facebook doesn’t have italics, and this is VERY important. )
    It is not enough to merely be well-trained in your OWN discipline. To be helpful in a Warm Zone event, you need to have been TRAINED IN THAT WORK. You need to have experienced what it’s like to train WITH the others, alongside them.

    Police methods and approaches — whether to a scene, an event, or a person — are (necessarily) different from typical fire or EMS approaches. Fire tends to look at the environment. Is the floor trustworthy? is the vehicle stable? where are the water sources? …EMS tends to look at the people. As we approach a person we are already assessing their breathing, color, body language. LE tends to look at potential actions: are they about to reach for something? if they run, which direction might they go? …. We all do our jobs well, BUT we all do our jobs differently, and that’s appropriate… UNTIL we need to coordinate closely; then there needs to be cross-training in specialised scenes. THAT is the training your writer did not have. That is the training you need before you make a decision.

    And I maintain that participation in a given Warm Zone rescue MUST be OPTIONAL for any Fire or EMS personnel that are asked. If a given fire chief wants to decline THEIR OWN participation in an event, fine — but [s]he should not prohibit a TRAINED member of their dept. from participating, if they wish to. Emphasis on TRAINED. Good intentions are not enough. A Warm Zone Rescue is sufficiently different from “normal” scenes, that in order to be actually helpful, and not a hazard or potential victim, the rescuer MUST have PRIOR training IN THAT KIND OF EVENT. It doesn’t have to be locale-specific — ie. if your Warm Zone Training took place in a school, and this actual event is happening in a mall, you should not be prohibited from taking part. It’s the concepts that are needed — concepts that can be really mind-stretching for the participants during initial training.

    For example, when I trained, it was very different for me to approach a patient/victim (they all were actors but they were very convincing!) NOT looking first at breathing & color but instead at their hands. We were trained to “look at the hands! BOTH hands!” and to control the hands — do not allow the patient to reach into a pocket, or underneath themselves, or towards a nearby object, don’t even let them flop around. Control the patient’s movements! — THAT is something I never heard in my EMT course. (I’m not saying it isn’t ever covered in any EMT courses; only that it was never mentioned in the one I took.) In a Warm Zone event, this concept is ESSENTIAL. It has TOP PRIORITY.
    See what I mean? the concepts needed in a Warm Zone MUST be introduced before it ever happens, and the personnel must get used to them & proficient with working within them, before the event.

    Please reconsider your stand on this important topic.

    Like

  16. Nice link bait. But this is the most disjointed grouping of partially coherent thoughts that I’ve seen in a long time. It’s very frustrating when we try to make essential changes in EMS doctrine and individuals who have very little understanding of the methods or the rationale offer confused yet strong opinions like these. I wish you had taken a little more time to try to understand the tactical advantage of rescue task forces before you chose to spread this ridiculousness. It significantly effects the credibility of your blog.

    Like

  17. I agree with much of the criticism leveled against this article.

    The author has cherry-picked studies, manipulated the discussion in a specific direction to reach their pre-determined objective, and periodically intermixes opinion as fact.

    As a bit of an aside, the author cites some studies regarding survivable wounds. On the battlefield, warfighters are wearing body armor that provides protection for the torso. Civilians do not. So it’s perfectly logical that civilians suffer a greater number of gunshots to the torso than warfighters do, but that isn’t any reason not to be prepared to save those that can be saved.

    I appreciate the point the author is trying to make. Despite the above, I do partially agree with them. I agree about the *untrained* aspect. Responders should not be tasked to enter an environment for which they were not properly trained to enter.

    But that’s where my agreement with the author ends. As others have stated, there are plenty of models in practice around the country. The Rescue Task Force was mentioned by several others. There are also dedicated TEMS teams that support several law enforcement agencies in a region. There are others I’m probably not aware of. The point is that there *are* models, and there *is* training. So the premise of the article, which is that any EMS personnel entering the warm zone are by definition untrained, is false. Since that’s the foundation of most of the author’s arguments, they start to fall away after that.

    As for law enforcement transport, the author should look at recent cases such as the Paris (Bataclan) and Orlando terror attacks. In both cases, the proximity of the attack to a hospital was such that both hospitals learned about the attack as the first patients were being brought in ad-hoc. It would defy logic to suggest waiting for EMS transport units when there is a squad car or even a bystander pickup truck available. Since hospitals in urban centers are common, it is reasonable to believe this could occur again. This is in addition to the incidents with longer transport times, for which other commenters cited studies.

    The article mentioned one aspect of Dallas, but left out another side of it. EMS personnel are very often trained to examine scene safety upon arrival. It’s as if it’s a checkbox that, once checked, doesn’t get revisited. What happens in the case of a Dallas-style attack with the EMS personnel who are already present? Having at least some tactical training, as is the case with departments that have implemented the RTF model, would provide them with critical skills to take appropriate action. In late July, an Oakland PD officer was involved in a car crash. As she sat trapped in her car, an individual who had no connection with the crash at all walked up to her car and opened fire on her. This started as a car crash, and no weapons were involved in the initial call. It was simply a matter of coincidental timing that fire/rescue hadn’t yet arrived when she was fired upon.

    Like

  18. This is just nonsense. The article was obviously not proof-read, and the use of foul language further proves my suspicion that this was written by some know-it-all wannabe. In what state of mind was he when he said the Hartford Consensus is not science or logic based. It breaks my heart to think that there is some young, inexperienced, and impressionable person out there reading this garbage, and believing it.

    Like

    1. If you have data that proves the contrary, that The Hartford consensus was in fact based on any evidence from civilian mass casualty shootings I would love to take a look at it. However if this is merely your opinion, you are welcome to that, but you are not welcome to your own facts.

      Like

      1. Mr. Behn,

        I encourage you to read this article that is fact-based, evidence-cited, and points out some flaws in your article. (http://threatsuppression.com/index.php/news-events/blog).

        In our eight-hour course, “Joint Public Safety Response to the Active Shooter” we cite more than 400 references to back up the stand that EMS needs to be involved quickly care at active shooter events. I would love to bring this course to your EMS agency. I think you would really enjoy a fact-based, scholastic look at response to the active shooter. On a selfish note, I’d love to do it in January or February so that I could do some skiing.

        Regards,
        Dr. Mike Clumpner

        Like

      2. I’m not sure of the validity of discussing events where law enforcement would not even go in, like the Pulse shootings, so clearly EMS could not go in . Until law enforcement changes their procedures it is not relevant to the discussion. It is still tragic, but if the area is not accessible to EMS because of an active threat, either real or perceived, I don’t think that is a warm zone.

        Like

      3. Sir,

        I definitely agree with your statement about the Pulse Nightclub shooting. If the police will not enter, it is obvious that the scene is not safe enough for EMS responders. Of course in retrospect, we found that the perpetrator feigned having explosive devices. The law enforcement response at Orlando has been critically examined by numerous law enforcement response experts. It should not take three hours for law enforcement responders to enter a scene when numerous people stated that people were actively dying inside. The Associated Press printed an article in which clubgoers stated that they were begging the police to enter to save the lives of their friends.

        At Columbine, there were 99 devices, 44 of which detonated. It took five bomb squads 72 hours to clear the school. We have to accept that there will be risks at these events, but we cannot simply wait for the “all clear” to happen. We wait for the “no obvious threat” and enter into that area (warm zone).

        As we approach the 15th anniversary of 9/11, we can reflect on the firefighters who climbed the stairs in the towers. Many of the firefighters knew they would not come out. But yet, they climbed on in hopes of saving lives. Their selfless dedication resulted in thousands of people successfully evacuating.

        Peter Cox with the London Fire Brigade summed up their agency’s opinion on an aggressive response in this quote, “We have far to great a reputational risk to be seen doing nothing”. Reputation aside, we have far to great a risk to allow innocent people to die inside waiting for help that refuses to enter.

        Feel free to email me at mclumpner@threatsuppression.com. I’d be more than happy to send you my dissertation that is replete with references and citations backing up an integrated response at active shooter events.

        Regards,
        Mike

        Like

      4. Regarding the math, the missing data that I did not include from the Blair and Schweit study (Page 11) is that an additional 10% of perpetrators killed themselves when law enforcement arrived (before law enforcement could engage) and another 13% are neutralized by the first arriving police officers.

        So based on this study, 92% of the perpetrators are dead, fled, or neutralized by civilians within the first 10 minutes of the attack.

        Regards,
        Mike

        Like

  19. You honestly don’t make a bad agruement…. But I don’t think you clearly understand what your saying here. Most of your statements and data are very true. But your talking about a “hot zone” with people actively shooting. The RTF model is entering a “warm zone” where the shooter is dead or barricaded in a room a safe distance away. Also saying EMS doesn’t have a role is a bit far fetched…. You mean to tell me that a police officer will do a better job with 14 patients in a CCP rather than some medic? I don’t think so. I am on board with police or even BLS transports…. Us medics tend to sit around on scene and start IVs and take forever when patients need blood and surgery…. Not saline.

    Like

  20. Medics enter dangerous situations every day: car wrecks, houses where domestic disputes occurred that haven’t been completely searched, even our patients are some times the emerging threat.

    What people like me advocate is better training, better equipment and more formalized front/first line integration between police and EMS at MCI scenes caused by violence.

    When EMS says “we will wait down the block until you say it’s safe enough for us,” we contribute to a vacuum of medical care for critically injured people who will die with out it.
    The result is that police will start performing that care, despite not being as well trained or experience in EMS techniques, don’t have a thorough understanding of triage (and who can wait), are not as good at moving patients. Even more importantly the police have another very important set of jobs to do (provide true security, arrest offenders, secure evidence…), and we need them to be head up, weapon up (if appropriate) and dialed in to doing their job well and trusting EMS will do its job well, rather than cops doing both jobs poorly while medics do nothing but wait.
    It’s not about sending medics into a gunfight, it’s about each service doing its own job really well and having a team approach to the overall management of a hyper-critical incident.

    Like

  21. This boils down to one principle…….. You do it your way, I’ll do it mine. If we’re looking at transporting in Police Cars, I have 3 or 4 calls each day for “Bumps and Bruises” which could be transported by the PD. If we are in the EMS Business, then we have to do our job, which includes treatment and transport of patients. We do NOT get to pick and choose. This whole subject is just totally moronic to begin with. The PD handles the Shooter, we handle the Wounded. Period. The ignorance thrown out in this article matches that of several others including “We should stop using Lights and Sirens” and “EMTs shouldn’t be allowed to request a Helicopter” ….

    Like

  22. This is quite a lively discussion, and for a good reason. None of us wants another person to fall victim to gun violence. Active shooter incidents present emergency responders with a multitude of contemporary problems; keeping our members safe and providing care for the wounded.
    I cannot contribute much more to the discussion than what has already been written. But, my two cents falls in line with the author of this article. And in addition to what has been written, there are labor issues, risk management, and implementation.

    Many departments are running out and purchasing Kevlar helmets and vests to place on their apparatus. When I ask what level of protection the jacket is rated for, I rarely hear anyone say they’ve bought level IV protection. This is what is required for these types of environments. When I ask if the individual receives a vest fitted for themselves, I’m told: “no, we purchase three or four for the apparatus.” Not good.

    The harsh reality is that the wounded who exsanguinate will do so in the first few minutes, long before we arrive. If the wound is survivable, the extra few minute for LEOs to suppress the shooter doesn’t make too much of a difference–except for the safety aspect of having a responder shot while entering the scene prematurely for someone who has died or would survive nevertheless.

    Not every person can be saved, but the incident commander can save more lives by keeping those who haven’t been shot from being shot. Arriving at a safe location near the incident and setting up the MCI protocols will typically take all the EMS responders you have. But doing so will excellerate getting those in need to definitive care quicker.

    Thank you each for your input, I realize each jurisdiction of different and that no one response mode will work for all agencies.

    Be safe

    Like

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out / Change )

Twitter picture

You are commenting using your Twitter account. Log Out / Change )

Facebook photo

You are commenting using your Facebook account. Log Out / Change )

Google+ photo

You are commenting using your Google+ account. Log Out / Change )

Connecting to %s