This seems to be the current hot topic in EMS. It’s easy to see why since the frequency of active shooter incidents has increased (slightly), as has the hysteria around them. Harsh word, hysteria, but it’s accurate. More importantly, the nature of active shooter incidents has changed from a lone gun man shooting up a store, mall, his former place of employment, or some other venue. We’ve started to see (Orlando) terrorist attacks involving indiscriminate shooting of civilians in public places.

Despite the best efforts of the lying media and lying politicians the Orlando shooting had nothing to do with Gay Rights. Other than perhaps, gays are even more despised than most other infidels to the Islmamofascists attacking our country ever frequently.

Political considerations aside, we’re very likely, almost to a certainty, to see more attacks like Orlando here in the US. That is, shooters who will have more than one firearm, may also have explosives, plan to kill as many people as possible, will (unlike previous active shooters) engage the police, and have dying in a blaze of glory as part of their battle plan.

In other words, acts of war instead of crimes.

Currently there are two schools of thought on active shooter response for EMS. The first, which coincides with one school of thought on police response, has EMS staging outside of the hot zone until the SWAT team goes in and neutralizes the shooter(s). That’s what happened at Columbine, the 2012 LAX active shooter incident, and Orlando.

The problem with that approach is that by the time the police have secured the scene, victims with survivable injuries will have bled out and died.

About 5 or so years ago, another school of thought emerged. In this approach upon arrival the first police officers went in to the hot zone to engage the shooter(s) and neutralize the threat. The officers did not wait for SWAT to arrive, but as soon as they had enough officers went in to confront the shooter(s). “Enough officers” could be two or four officers. EMS would not be staged, but would respond to the scene and go in behind the initial officers to look for victims. They would be escorted by four or so officers to provide them with protection in case a shooter was still around or had been missed by the first team in. This is referred to as “warm zone” operations.

Which brings me to a blog I discovered quite by accident.

EMS QA QI has been around for a few months, but doesn’t post all that frequently. I’ll be a frequent visitor since what I do now involves QA and QI for EMS. What brought me to the blog is this post,

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.

I agree, at least in part, with this thought. I’d go further and say that it’s an idea based on no science. Rather, it’s an idea based on the need to DO SOMETHING about patients with survivable injuries not getting care in time to save their lives. After all, saving lives is what we fancy ourselves doing.

EMS in the warm soon is a bad idea because it puts providers in measurable danger while not necessarily helping patients. I’ll talk more about that in a minute.

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 can imagine the response this idea got. People got their panties in a wad at the idea that EMS just drives people to the hospital. After all, in many systems paramedics don’t just drive people to the hospital, they drive people to the hospital after wasting time doing useless ALS procedures.

I don’t think that the police should be driving patients to the hospital. I also don’t think that the police think that they should be transporting patient to the hospital.

There are two things that need to be done to expedite getting patients out of the warm zone and into ambulances.

1. Treat immediately life threatening injuries. Mostly bleeding, but also correctable airway issues.
2. Extract the patient from the scene of the attack and get them to EMS.

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.

And this is where I am going with this. I don’t know that putting these kits next to the AEDs is the exact way to go, but I think putting the resources for self care in certain venues and training staff at those venues to use them is a good idea. Schools, malls, movie theaters, and now night clubs and sports venues are likely targets. They also have some sort of security and other staff that could be trained to do basic treatments for bleeding control.

Where I think that the author is going off track is looking at limited data with civilian shootings. A more apt comparison might be what the military relearned in Afghanistan and Iraq over the past 15 years. Many soldiers died because of extremity wounds with controllable bleeding that was not controlled.

In this country, we need only look at Columbine and the LAX shootings. At Columbine one teacher bled to death slowly because EMS was not allowed inside the perimeter and there were no first aid supplies on scene. A student with a critical, almost fatal, head wound crawled out of the school under his own power. At LAX the TSA officer who died bled out while multiple police officers walked past him numerous times and the paramedics were held outside the scene waiting for it to be secured.

It would seem reasonable to think that teaching people basic first aid and giving supplies and a way of extraction non walking patient would  be a reasonable approach.

For the venues I mentioned, this would come down to training and planning. Police and EMS should work with the management to identify escape routes, rallying points, and locations for supply caches.

A lot of people who can self extract will if they are able. If they have wounds that can be treated by someone before they are extracted, all the better.

You should read the entire post and while doing so, keep in mind the changing paradigm of active shooter incidents. Keep in mind that more and more active shooter attacks are also going to include an explosive attack component. The Columbine attackers were way ahead of the curve on this approach. Their plan was to blow up the school using multiple home made bombs and then use their firearms to finish off any escapees. As it turned out, they were inept bomb makers, so the plan fell apart.

We can’t count on that in the future. The Boston Marathon bombers made very good bombs. Their mistake was placing their devices a couple of hundred feet or so from the main medical tent for the event. Had they not done that, the death toll would have been much higher. What saved the victims with serious extremity wounds? Tourniquets. Oh, and the proximity of a 100 or so well trained and equipped EMS providers who had them.

So, while we’re on the subject of victim self care, I found this article today.

Dallas rolls out trauma kits to help civilians stop the bleeding in active-shooter drill

But he also made it very clear: The trauma kits introduced Tuesday were not a response to the ambush that killed five officers and wounded nine others.

Rather, Eastman said, this was part of a citywide effort to make Dallas “the most safe municipality to live in.” The kits, he said, are being rolled out citywide as part of President Barack Obama’s policy directive concerning national preparedness, which tasks civilians with tending to the injured until rescue workers arrive.

“Hemorrhage control,” Eastman said, “is the CPR of the 21st century.”

He demo’d the kit on two actors depicting gunshot wound victims — a man with leg and arm injuries, and a woman with a gaping chest wound.

“If my mom can do it,” he said, after wrapping their wounds, “anybody can do it.”

As  regular readers will know, I’m not exactly a fan of President Obama, but credit must be given where credit is due. It is however, a sad commentary when the President admits via policy that we are going to “absorb” more terrorist attacks. That’s a topic for a different post and a different timd.

There’s a video at the link that’s worth watching. It’s from a news cast, so it’s not very detailed, but it’s worth watching.

It’s certainly an idea worth thinking about.