Towards the Sound of Shooting
A new response to the active shooterBlake Iselin
Firefighter/Paramedic
Arlington County Fire Department
The Reality
Active shooter incidents happen everywhere in this country, from the small town to the largest cities
Easy and effective
Low cost
Can be obtained easily
The Reality
WMD’s are hard to acquire
Expensive
Require significant resources and training
Larger chance of being detected
The Reality
Police agencies have made signifiant changes in their response since Columbine and are extremely aggressie when responding to an active shooter
Fire/EMS agencies have not, they still stand outside till the police have secured the entire building
This leads to the injured not receiving treatment and dying from wounds they received
The Reality
Fire/EMS needs to take a more progressive response and assume more risk to save lives.
Risk is nothing new the the fire service, we are willing to enter a burning building, confined spaces, hazmat releases, etc. to save lives.
The risk is mitigated by the use of SCBA, turnout gear, training, equipment, and SOP’s
The Reality
In the active shooter incident the risk is mitigated with the use of ballistic gear, security, equipment, SOP’s and training.
The environment in an active shooter incident is more controllable then that of a building on fire.
New Response Goals
Provide rapid treatment to the wounded
Prevent those who have survivable injuries from dying
Use resources more efficiently and effectively
Evacuate the wounded to definitive care sooner
Provide the proper gear and security for the operators
Rescue Task ForceUse the military medicine doctrine of Tactical Combat Causality Care (TCCC)
Use both Police and Fire assets in the capacity that they are trained and equipped for
Provide the proper PPE for those operating in the warm zone
Drastically reduces the time till treatment of the wounded begins
Able to treat a large number of victims with minimal resources
RTF RTF MedicineMedicineWarm Warm
Zone careZone care
RTF MedicineThe Doctrine of Tactical Combat Casualty Care Following the SEAL casualties sustained during the invasion of Panama, the Navy Special Operations community conducted an extensive review of combat death and trauma care.
The concept of TCCC is developed in 1996 after an extensive analysis of the Vietnam Casualty Database.
RTF MedicineThe Doctrine of Tactical Combat Casualty Care
Treat patient as quickly as possible at or near the site of wounding despite the still-fluid tactical situation.
Use stop-gap measures at the site of injury to manage the preventable causes of death on the battlefield.
Rapid evacuation from the threat environment to care
RTF MedicineHow people die in ground combat
Bellamy, RF. Causes of death in conventional land warfare, Military Medicine. 1984
RTF MedicinePreventable causes of death
15% of Ground Combat Deaths are Preventable
RTF Medicine9% KIA Bleeding to death from extremity wounds
RTF Medicine9% KIA Bleeding to death from extremity wounds
Normal Normal Blood Blood
VolumeVolume
Death Death probableprobable
RTF Medicine5% KIA Tension pneumothorax
RTF Medicine1% KIA Airway obstruction
RTF MedicineWarm Zone care
Stabilize injured using SCAB-E assessment and treatment
Situation
Circulation
Airway
Breathing
Evacuation
RTF MedicineWarm Zone care
Death from Hemorrhage ; 1 - 3 minutes
Death from Airway compromise; 4 - 5 minutes
Death via Tension Pneumothorax; 10+ minutes
“Golden Hour” for Shock 60 minutes
Why do we use the Acronym : SCAB???Why do we use the Acronym : SCAB???
It is pointless to treat a casualty for a developing tension It is pointless to treat a casualty for a developing tension pneumothorax while he is dying by strangulation from a pneumothorax while he is dying by strangulation from a
compromised airway or by uncontrolled bleeding.compromised airway or by uncontrolled bleeding.
RTF MedicineWarm Zone care
Secondary devices
Rapid triage/treatment of all victims in reasonable geographic area
Directed evacuation of those able to self evacuate
No CPR
SituationSituation
RTF MedicineWarm Zone care
Critical focus on stopping life-threatening bleeding
Supported by combat data as most likely injury as well as most common cause of death
Technique of choice is tourniquet
Quick, effective, and easy to apply
Multiple published studies show safety if removed in less than 2 hours
Subsequent rx aimed at de-escalating from tourniquet
Other option is pressure dressing with wound pack
CirculationCirculation
Total or partial amputations
Large deep lacerations or extensive tissue damage with heavy bleeding
Massive arterial or venous bleeding
When in doubt, tourniquet is placed
Circulation - Tourniquet usageCirculation - Tourniquet usage
RTF MedicineWarm Zone care
RTF MedicineWarm Zone care
RTF MedicineWarm Zone care
Quick, easy to apply
Designed to use mechanical advantage and elastic bandage to put direct sustained pressure over wound
Must use packing for deep wounds
Incorporates large absorbent dressing
Circulation - Pressure DressingCirculation - Pressure Dressing
RTF MedicineWarm Zone care
Certain types of life-threatening hemorrhage cannot be controlled by a tourniquet because of anatomical constraints.
Head, neck, and high groin area
Circulation - Hemostatic AgentsCirculation - Hemostatic Agents
RTF MedicineWarm Zone care
Hemostatic agents incorporate proteins or chemicals designed to initiate and accelerate the fibrin clotting process.
When used with sustained direct pressure, hemostatic agents help to seal the damaged arteries and veins involved in uncontrolled hemorrhage.
Circulation - Hemostatic AgentsCirculation - Hemostatic Agents
RTF MedicineWarm Zone care
Emphasis on basic airway skills
Nasal trumpet placed on all patients with altered mental status
Effective regardless of gag reflex
Relatively stable once placed
Stimulating to transiently unconscious patient
Patients placed in recovery position or position of comfort while waiting evacuation
AirwayAirway
RTF MedicineWarm Zone care
Focus care for penetrating chest wounds
Immediate application of occlusive dressing for any wound from umbilicus to trapezius
Proactive needle decompression for any patient with thoracic injury and respiratory distress
BreathingBreathing
RTF MedicineWarm Zone care
Depending on the building, injured are evacuated to the CCP or cold zone
Additional RTF’s needed
Make use of surrounding resources (moving carts, wheel chairs, etc)
EvacuationEvacuation
RTF OperationsRTF Operations
RTF Operations
The RTF consists of 2 police officers and 2 medics
Officers provide front and rear security and control movement
Medics provide treatment and evac. of the wounded
RTF operates in the warm zone
RTF Operations
As the contact team moves through the building searching for the threat, location of wounded is relayed back to command
After the contact team either neutralizes the threat or contains it the RTF is deployed
RTF proceeds to the location of the wounded and begins treatment
RTF Operations
The objective of the first RTF is to treat the wounded until they run out of equipment or run out of wounded to treat.
Then they switch objectives and begin evac of the wounded.
The second and subsequent RTF’s begin evac of those treated until the team ahead of them runs out of equipment and then they leap frog forward to finish treatment.
RTF Operations
RTF Operations
RTF Operations
RTF Operations
RTF Operations
RTF Command and Control
These types of incidents are very dynamic and the number of threats, victims, etc can change at any time.
The first Fire/EMS supervisor and the first arriving PD command officer need to form a Unified Command.
The number of RTF’s formed is based on the availability of resources both FD and PD.
The location of the CCP is based on the building type, number of victims, threat location, resources, and environmental conditions.
Movement is controlled by the police element of the unified command
RTF Command and Control
Fire/EMS CommandEnsure adequate resources are available for the incident and number of victims.
Track the location of the RTF’s through the building
Track of the number of victims and their locations in the building
Ensure the MCI areas are established and are supplied
Ensure an equipment cache is available to restock the RTF’s and treatment areas as needed
RTF Command and Control
Police CommandTrack the location of the Contact team(s) and location of the threat(s)
Track the location of victims reported by the Contact team and deploy the RTF to those areas.
Ensure adequate resources are available to suppress the threat and to staff the RTF
Track the location of the RTF
Share intelligence with the FD as part of the Unified Command
RTF CommunicationsFire/EMS
Stay on the Fire/EMS ops channel
Provide location of RTF
Number of victims
Additional RTF needs
RTF CommunicationsPolice
Stay on the police ops channel
Provide location of RTF
Location of additional threats
Any change to the security of the RTF
RTF EquipmentBallistic and Medical
RTF EquipmentBallistic
PPI level IIIA Hornet Tactical Vest
PPI level IV Rifle Plates (Chest and Back)
PPI level IIIA Special Ops. Helmet
RTF EquipmentMedical - Vest Mounted
M.E.T Gen-III Tourniquet x 2
H-Bandage pressure dressing x 2
Celox gauze x 2
Halo chest seal x 2
NP airways x 2
14ga. 3.5” needles x 2
Tegaderms x10
RTF EquipmentMedical - Jump Bag
M.E.T Tourniquet x 6
H bandage pressure dressing x 6
Celox gauze x 6
Halo chest seal x 6
NP airways x 6
14ga. 3” needles x 6
Tegaderms x 20
RTF EquipmentMedical Emergency Tourniquet Gen-III
Lightweight.
Does not need to be fully cinched tight before operating windlass.
Aluminum Non-breakable windlass.
Simple operation.
Can be applied and secured in seconds.
RTF EquipmentH-Bandage
Easy to apply
Large absorbent dressing
Elastic ace wrap with velcro
Easy to secure
Ceramic H for mechanical pressure
Well attached so may be used to fulcrum bandage for pressure
RTF EquipmentCelox Guaze
Various forms
Works in all temp ranges
Works on heparinized/coumadin blood
Can be used as a burn bandage
RTF EquipmentHalo Chest Seal
Two large seals
Gel based adhesive
RTF EquipmentNP and 14ga.
Questions?