Depending on the service area covered by a particular EMS provider, most of us will respond to one or more gunshot victims a career.
These may range from drive-by shootings to accidental trauma to self-inflicted gunshots to hunting accidents. The locations of most gunshot victims have an element of scene safety to consider, but most incidents are usually limited in scope with enough resources to secure the scene and treat the presenting patient or patients.
An active shooter incident is loosely defined by law enforcement as one in which a shooting is in progress and the situation may require a response which is different from standard practice [1]. The active aspect is important because, unlike a homicide or other completed crime, law enforcement or other responders may have an opportunity to alter the outcome of the situation. These situations are more specifically described by the FBI as “an individual actively engaged in killing or attempting to kill people in a confined and populated area” [1].
The power of data
In 2014, the U.S. Department of Justice released an analysis of 160 active shooter incidents from 2000 until 2013. During that time frame, 1,043 casualties, including 486 fatalities, were the result of shootings in 40 states and the District of Columbia. The DOJ study found that active shooter incidents can occur in any size or type of community meaning that all emergency responders need to prepare for a scenario like this one [1].
As the report details, there are themes common to many of these incidents:
- Predominantly male shooters (96.25 percent of incidents)
- Predominantly a single shooter (98.75 percent of incidents)
- Often resolved in five minutes or less (70 percent of incidents where a length could be determined)
These themes have grown into data-driven recommendations for both law enforcement and EMS providers on how best to respond to active shooter incidents. Because these incidents are high profile and evolve quickly, standard responses — like waiting for SWAT and tactical EMS personnel to arrive — are likely to be ineffective and responding units need to take a more proactive role early on in the incident [2].
Changing roles for police, fire and EMS
The traditional response to a shooting with a barricaded suspect had law enforcement to establishing a perimeter with EMS staged outside and waiting for SWAT to respond before making entry. With the advent of data-driven recommendations, officers are now asked to immediately enter the scene and engage with a shooter as prior evidence shows that this action has an excellent chance of bringing the incident to a close [1].
Similarly, fire and EMS agencies are being asked to treat these incidents more like hazardous materials scenes with defined hot, warm and cold zones. Given that these incidents are often perpetrated by a single shooter, once law enforcement has neutralized the shooter the scene essentially becomes a warm zone. SWAT and tactical medic resources are still needed for a detailed search of the premises but first responders, under police cover, can now begin to triage, stabilize and extricate wounded individuals [2].
This is an important step forward as the injuries sustained by victims of an active shooter are often dependent on rapid application of bleeding control and surgical repair.
The acronym to remember for active shooter response is THREAT:
- Threat suppression (law enforcement)
- Hemorrhage control
- Rapid Extrication
- Assessment by medical providers
- Transport to definitive care
This acronym combines the best available evidence about active shooters with evidence-based practice for trauma care [2].
Treatment priorities
Wounds sustained by victims of an active shooter can be broadly characterized as extremity or core injuries. Penetrating wounds to the extremities are already known to be effectively treated by early application of a tourniquet. Provided that a tourniquet is correctly applied, patients with these injuries may be considered stable for a period of time.
Wounds to the head, chest and abdomen are largely considered surgical in nature. While hospital capabilities and available surgical suites may vary from system to system, transporting these patients rapidly to an appropriate trauma center is critical to their survival.
Establishing a casualty collection point allows extrication teams to avoid extensively triaging patients in the warm zone and instead to bring all patients out of the scene to be triaged and readied for transport. Care of victims during extrication should be limited to rapid application of bleeding control and removal to a casualty collection point [2].
Recently the White House, in conjunction with the Department of Homeland Security, launched the Stop the Bleed campaign to educate the lay public about hemorrhage control for everyday emergencies and mass casualty incidents, including an active shooter. Consider adopting this program for community outreach events or pre-positioning bleeding control kits in high-risk venues or those where there are a number of trained lay people.
Case conclusion
You pull up on scene and the engine crew meets up with their law enforcement escort. After donning body armor — ballistic vests and helmets — the extrication team proceeds into the building with bags of tourniquets and hemostatic dressings.
You and your partner establish the casualty collection point and advise incoming ambulances of the ingress and egress routes to the scene. You open your agency’s active shooter handbook and notify both your local agency contacts as well as those from your mutual aid agencies and the area hospitals. Finally, you and your partner prepare to receive the first wounded victims as the extrication team comes out of the building.
References
- Blair, J. P., & Schweit, K. W. (2014). A Study of Active Shooter Incidents, 2000 - 2013. Texas State University and Federal Bureau of Investigation, U.S. Department of Justice, Washington D.C. . Retrieved from https://www.fbi.gov/file-repository/active-shooter-study-2000-2013-1.pdf
- US Fire Administration. (2013, September). Fire/Emergency Medical Services Department Operational Considerations and Guide for Active Shooter and Mass Casualty Incidents. Retrieved from https://www.usfa.fema.gov/downloads/pdf/publications/active_shooter_guide.pdf
