Updated June 2015
In 2008, shortly after the Virginia Tech shootings, the Arlington County (Va.) Fire Department participated in an active shooter drill with local law enforcement. In a simulation at Marymount University, police followed the trail of dead and dying in the hunt for the shooter, who had barricaded himself inside the library.
Meanwhile, paramedics and EMTs staged in a parking lot more than 100 yards away and waited. “After about 30 minutes, police had the ‘bad guy’ and had marked the IEDs and brought out one or two injured people,” recalls E. Reed Smith, M.D., Arlington County Fire Department’s operational medical director. “Two hours later, we were still staged, and most of the injured were still inside. We could see injured people, but we couldn’t go in and get them. Myself and the special operations chief said, ‘This is ridiculous. We can’t just stand around. Why are we not moving in? The threat has been mitigated.’”
Wanting to be able to do more in real-life situations, Arlington County fire and police soon began to work together to develop a plan for responding to active shooter events that would give firefighters access to victims more quickly. Under the plan, rather than wait for police to declare a scene 100% safe, EMTs and paramedics wearing bullet-resistant vests and helmets would enter the building under police escort as soon as police determined there was no obvious threat, such as if the shooter had moved to another area of the building. Calling it Tactical Emergency Casualty Care (TECC), Smith and his team adapted their plan from the U.S. military’s strategy for taking care of the combat wounded, in which responders are trained to quickly assess the wounded, dealing on scene only with specific types of life-threatening yet treatable injuries.
“This is paradigm shifting,” Smith says. “We accept a lot of risk in the fire service when you go into a burning building or respond to a hazmat call. You mitigate those risks with proper personal protective equipment, the right tactics and the right SOPs. Why can’t we bring that concept to an active shooter incident and use law enforcement for law enforcement and us for the medical stuff, and have the fire department assume some risk and use the skills that save lives?”
Though Arlington County is at the vanguard of planning for active shooter events, they’re not alone. Fueled by a seemingly endless string of deadly shootings in schools, universities and movie theaters—as well as a growing urgency in law enforcement and the federal government to do more to thwart these tragedies—some individual agencies and large fire and EMS organizations are beginning to ask hard questions about how EMTs and medics can better respond to active shooters.
The U.S. Fire Administration is preparing a detailed operational guide for responding to active shooters. And in April, the International Association of Fire Chiefs (IAFC), the International Association of Chiefs of Police (IACP), the FBI and the Department of Homeland Security (DHS) held a summit at the IACP’s Washington, D.C., headquarters to discuss improving active shooter response.
“One thing we hear from physicians is that a lot of patients in active shooter situations can be saved,” says IAFC CEO and executive director Mark Light, whose organization is preparing a position statement on the importance of developing active shooter response plans. “It’s critical we know how to do that.”
Yet significant gaps remain. In February and March, the IAFC conducted an online survey about how fire departments prepare for active shooter events. The survey found:
- 75% of respondents didn’t have specific response protocols in place for active shooter incidents.
- About 44% of those that didn’t were working on protocols or had plans to start developing them soon.
“We were surprised by the large number that didn’t have operational plans to address this, given the high visibility of the shootings,” Light says.
The National EMS Management Association is watching the fire service’s efforts closely, says Ryan Greenberg, a NEMSMA board member who attended the meeting and is heading up an initiative to develop active shooter response best practices. “In many of the situations we respond to, our jobs and our roles are independent of each other,” he says. “Now we are getting into situations where our jobs are dependent on each other. We need law enforcement to secure an area. Law enforcement needs us to care for patients. We need law enforcement to get patients to us or get us access to patients. And we need law enforcement to ensure our safety while we’re caring for those patients.”
Interest in EMS’s role in active shooter response extends to the White House. President Obama’s plan to reduce gun violence, issued after the shootings at Sandy Hook Elementary in Newtown, Conn., directs DHS to seek the input of first responders on best practices for improving preparation and response to mass casualty shootings. Also this spring, Greenberg was one of more than 100 fire, EMS and law enforcement representatives invited to attend a conference led by Vice President Biden on reducing gun violence, during which guidelines to help schools, universities and houses of worship respond to active shooters were released.
“The release of these documents brings tremendous opportunity for EMS systems across the country to become more involved and better prepared in the event we have to respond to such an event in our own community,” Greenberg says.
It’s about time that fire and EMS get prepared, Smith says. “We spend millions upon millions of dollars for WMD preparation, which more than likely isn’t going to happen,” he says. “Bombs and bullets kill the most people. Acquiring them is easy, it’s inexpensive and anybody can do it. That’s why you see it happening all the time—and yet there is very little training for fire and EMS to deal with it.”
Following law enforcement’s lead
Years before the term became known to fire, EMS and the community at large, police were already well acquainted with the term “active shooter.” Law enforcement defines an active shooter as an individual actively engaged in killing or attempting to kill people in a confined, populated area using a firearm and sometimes other weapons.
Traditionally, police response was based on experiences with hostage situations. The assumption was that the perpetrator was after something specific, like money, or the release of political prisoners. “The thinking was the bad guy didn’t want to kill people,” Smith says. So police would seek to control the scene, call for the specialists—SWAT—and try to communicate or negotiate with the suspect.
But the 1999 shootings at Col-umbine High School changed all that. On a spring morning, two students armed with rifles, shotguns and homemade bombs gunned down 13 people and wounded 24 before committing suicide. Officers responding to Columbine did what they were trained to do: set up a perimeter to contain the shooters and wait outside for SWAT.
Over the course of 45 minutes, the teens stalked the hallways of the school. It was nearly an hour after the first shots were fired that SWAT entered the school and four hours before all students and teachers were evacuated. One of them, a teacher, bled to death 3.5 hours after he’d been shot, still inside the building. His students, hiding in a science classroom, held signs up to the window telling police he was dying.
“Because of Columbine, the police community realized the tactics and the concepts were flawed,” Smith says.
Police response to active shooters underwent a fundamental change. Instead of waiting for SWAT, the first patrol officers to arrive on scene are taught to enter immediately, usually in teams of four. They’re trained to step over the dead and wounded, follow the sound of gunshots and pursue one objective: stop the shooter any way they can to prevent further mayhem.
The shift in police tactics took hold quickly. In the 2001 Santana High School shootings in Santee, Calif., officers were inside the school within moments. According to news reports at the time, they captured the 15-year-old shooter within six minutes of the first shots being fired.
Yet even as police response changed, Smith says, fire and EMS largely didn’t, and continued to stage on the perimeter of such incidents. One reason EMS hasn’t changed is that no one has demanded it, he adds. “The police were faulted for what they did in Columbine. We have never been faulted for it,” Smith says, “although you are starting to hear some discourse on the EMS response, particularly involving Aurora.”
On July 20, 2012, 12 people were killed and 58 wounded when a lone gunman opened fire during a midnight screening of the film The Dark Knight Rises. According to a fire department internal review released in May, fire engines attempting to get to the injured were stuck in gridlock by parked cars, police vehicles and 1,400 fleeing moviegoers, while other engines and ambulances sat idle in a staging area. The review found that it took 17 minutes for fire dispatchers to tell EMS that there were victims inside the theater who needed medical attention, even though police officers had been telling police dispatchers they needed medical help for seven minutes before that.
Room for improvement
In Arlington, the basic plan for firefighter response to active shooters goes like this: During an active shooter incident, the first team of four police officers enters the building to hunt for the shooter. As additional officers arrive on scene, they, too, enter the building in teams of four, going room by room and hallway by hallway looking for additional shooters or explosive devices.
Under TECC, a third wave—teams of two medics or EMTs partnered with two police officers—enters after an area has been declared cleared—meaning there is no obvious threat—but before police conduct the methodical search that can take hours to declare a scene safe and secure. Called a rescue task force, additional teams of police and EMTs or medics would enter depending on conditions and the number of victims.
“It can’t be a specialized team—it takes too long to get them there,” Smith says. “The people who are dying are going to be dead.”
Among the injuries responders treat immediately on scene: stopping bleeding using tourniquets, closing open chest wounds and treating tension pneumothorax. “It’s doing quick things to save the ones who are savable,” Smith says, citing research from the Vietnam era that estimates about 15% of battlefield mortalities could have been avoided by relatively simple steps such as stopping hemorrhaging with tourniquets.
Precisely what would be done on scene depends on the level of threat, according to the TECC guidelines. But generally speaking, responders move on to the next patient as soon as one is stabilized. Likewise, any injury that isn’t immediately life-threatening waits until the victim can be evacuated outside to additional EMS personnel.
In developing the plan, Smith borrowed heavily from the military’s Tactical Combat Casualty Care (TCCC) while adapting it to reflect civilian constraints such as liability, scope of practice and medical protocols.
The IAFC’s position statement will outline other key considerations for fire and EMS, including the need for joint training and using consistent terminology when developing plans so that the various responders are speaking the same language on scene. “In the fire service, when you say, ‘All clear,’ it means they have searched the floor and there are no victims,” Light says. “When police say, ‘All clear,’ does that mean no victims or no shooter? There needs to be integrated planning and practical exercises across all disciplines.”
Another key point is getting support and cooperation from police. With one fire and one police department serving an area spanning 26 square miles, Arlington was able to get law enforcement buy-in quickly. But in areas where various jurisdictions overlap, that can be more complicated. In Prince George’s County, Md., for example, the fire department covers an area that’s served by 21 police departments, Light says, meaning there will be lots of legwork to get everyone on the same page of an active shooter response plan.
Another consideration is making sure firefighters or EMS responders don’t get mistaken for a shooter. To alleviate those worries, Smith and his team worked out a system of communications in which police would use one channel to relay information about the scene and the shooter to the command center, while fire would use a second channel to communicate medical information, making sure that everyone is using the same terminology and that command knows exactly where everyone is in the building at all times.
Preparing for the unthinkable
As fire and EMS grapple with how best to respond to active shooter incidents, one central question is just how much risk responders should be expected to take on. While many Arlington firefighters eagerly embraced the active shooter guidelines, some were afraid they would be put in harm’s way, according to Smith.
But by entering only “warm” zones, going in with police and wearing proper protective gear, Smith believes the risk is minimal—especially when compared to other risks that EMS and firefighters take on as part and parcel of their job. “What kills more firefighters every year? Fighting fires,” he says. “What kills EMS? Turning on lights and sirens.”
One thing is unfortunately clear: Active shooter killing sprees will likely continue. Between 2006 and 2012, there was an average of 15 incidents in the U.S. annually in which two or three people were killed, according to a study by the New York City Police Department. And although these incidents are relatively rare, they can happen anywhere, anytime, in big communities and small, Light says. He likens preparing for active shooters to the firefighters who responded to the recent 777 crash at San Francisco Airport. “That will hopefully be the only large-body jet they will ever see crash,” he says. “But some of them trained their entire career, 20 or 25 years, for that.”
