Mass Casualty EMS Response with Tactical Protection

Host Agency: Brookline Police Department

This scenario will test the ability of regional EMS personnel to provide mass casualty triage and expedient field treatment of multiple casualties while law enforcement tactical Teams provide force protection. This training scenario will result in intra-agency and multi-discipline integration and coordination.  Tactical Teams will neutralize known suspect(s) and provide tactical protection for responding EMS personal.

Regional EMS personnel  will respond to a (warm zone) environment providing emergency medical treatment prior to the area being completely (cleared) of additional suspects. EMS personnel will be provided training prior to the scenario to better familiarize themselves with working in a “tactical” environment.

This will incorporate reviewing medical skills pertinent to this type of operation including the use of tourniquets, hemorrhage control with homeostatic agents, and rapid assessment and treatment techniques.

Teams will use and evaluate the Armored Mobility Inc. (AMI)-Mas-3818 Mobile Armored Shield, MSA Releasable Assault Vest (RAV), Z Medica Quick Clot, North American Response Products-Combat Application Tourniquet (CAT),Conterra-Medical Kit Bags, triage Lights-LED Identification Lights and Blackhawk-VTAC Slings during this scenario.

Here is the situation. You are doing an EMS medical standby for an ongoing “active shooter” incident. All you and your crew know is that a disgruntled ex-employee went into the office where he was previously employed and started shooting people. Rumors are that he was shot and killed by police in a “suicide by cop” manner. There is uncertainty among the first responders, and the law enforcement officers are not sharing much information. Fleeing employees report that at least several people inside the office are critically injured and are in immediate need of medical care.

Active shooter incidents are not uncommon in the United States. This type of incident is a frequent headline and is likely to happen in your jurisdiction at some point. Let’s look at three possible courses of action regarding this hypothetical event.

Option A- Grab your medical gear and get into the building ASAP and start triage, treatment and extrication.  You believe you do not need a police escort as it is highly likely that the shooter was by himself and was the only threat. Law enforcement has a job to do and you have yours. There need not be a whole lot of interaction with the cops as your EMS medical team should focus on saving lives.

Options B- You and other EMS personnel are not going to get close to this crisis site until you are given an “all clear” by law enforcement and you are assured that the office and rest of the building has had a thorough sweep looking for other threats. This may take an hour or more because another shooter could be hiding or the perpetrator could have placed an explosive device somewhere in the building. The search must include every potential hiding place. People may be bleeding to death, but one “never knows”, and it is “better to be safe than sorry”. After 2 hours, the scene is deemed “clear” and you are allowed to enter.

Option C- Once law enforcement is reasonably certain the shooter is accounted for and neutralized, then a quick sweep of the area is completed. Your EMS team then enters the scene with a law enforcement escort. You enter this “warm zone” and begin triage, treatment and extrication, while the law enforcement team surrounds and protects you from any “two legged” threat.

Figure 2 During a full scale training event, law enforcement escorts EMS providers into a scene after the “shooter” has been neutralized.

Option A is obviously dangerous, and Option B is far from ideal in that valuable time is lost and lives are further endangered. I am making a case for Option C. This course of action is not to be taken lightly and should include a significant amount of pre-incident preparation. This preparation should include joint training and exercises, as well as policies and procedures that have been pre-established. Both law enforcement and EMS need to build a trusting and mutually respectful relationship for this effort to be successful.

Several agencies across the nation have successfully begun to employ such an approach and this trend needs to continue and be widely implemented.

Let’s first examine the “active shooter” scenario vs. a terrorist attack. Active shooter incidents can be defined as, “an armed person who has used deadly physical force on other persons and continues to do so while having unrestricted access to additional victims.

In a recent informal research project, several common themes are apparent in active shooter incidents. First, the perpetrators are virtually always males, usually Caucasian. Very important to note is that in the vast majority of active shooter incidents, the shooter acted alone. Columbine was an exception with both Harris and Klebold involved in all aspects of the incident. Another point to consider is that in a review of 25 separate active shooter cases, most incidents were “over” within 10-15 minutes. “Over” meaning the perpetrator had committed suicide, was killed by police, placed under arrest or fled the scene.  This is significant in that many minutes or even hours may be lost by a slow methodical search of the office, school or workplace. Another finding was that explosive devices were rarely used.  Columbine was an exception in this regard.

Active shooter incidents can be further broken down into two main types of attacks: spontaneous and well planned.

Spontaneous or near-spontaneous shootings

Spontaneous active shooter incidents are often initiated by a subject who experiences a significant negative event. It could be job termination, a bad employee review, bullying, isolation or some kind of mental breakdown. This may be the “last straw” for someone who is has been ready to act out and may have been fanaticizing about some kind of retribution. In several situations the perpetrator has left the premises to retrieve a firearm, then go back in and start killing people, some on purpose, others at random.

These types of incidents have a few common themes. First, there is little premeditation and planning. It is common for the action to take place on the same day as the “triggering event”. Second, most attackers do not plan on surviving. In some cases they kill themselves after the initial “flurry,” or when cornered or pinned down by law enforcement. They also have been known to perform “suicide by cop” where they confront law enforcement in an aggressive manner, often with gun in hand, and law enforcement obliges with good reason, and ends the event. It ends only for the perpetrator though; the MCI has only begun.

Planned shootings

While planned shootings are far less common than spontaneous events, they present additional complications and usually result in more casualties. Some examples include high profile events such as Columbine (Harris, Klebold), Virginia Tech (Cho) and Fort Hood (Hasan) and most recently Tucson, AZ (Loughner). These incidents are often planned to be terminal for the perpetrator.

Planned incidents are of a bit more concern to law enforcement as the perpetrators may factor in police and EMS response to their sequence of events and countermeasures. They may chain or lock doors, plant booby traps, disable surveillance cameras, etc. On occasion improvised explosive devices have been planted.

This kind of pre-planning accomplishes several goals for the shooter. Intended targets are less likely to escape or may be herded towards a “kill zone”. This can also delay the first responders, and buys time for the perpetrator to execute more people. Simply stated, the more time the perpetrator has, the more casualties there will be.

Regardless of the nature of active shooter situations, law enforcement clearly recognizes the need to get into the crisis site and distract, neutralize or eliminate the threat and reduce the number of potential casualties.

Over the last decade, law enforcement has made significant strides and improvements in the response to active shooter incidents.

Historically, local law enforcement might wait for a well armed and trained SWAT team to make the entry into the crisis site. Clearly this delay allows the perpetrator to continue unimpeded in his efforts and more lives could be lost. Law enforcement response to active shooter situations now encourage taking whatever assets are immediately available and become a “contact team” with the sole purpose of distracting, making contact and engaging the shooter as soon as possible. This requires the contact team to simply go towards the sound of the shots. This approach is called “Immediate Action Rapid Deployment” (IARD) and is now widespread and accepted in the law enforcement communities.

What is less clear and ill defined is the EMS medical response procedure. Simply stated, we know that the more delay in getting EMS into the crisis site to render care, the more likely morbidity and mortality will go up for the victims.

It is imperative to insure that EMS providers are not put in harms way and are not allowed to enter a scene unescorted where there still might be a threat. Once the threat is eliminated or isolated, which statically happens very quickly, the scene is no longer a hot zone. A quick sweep from a SWAT team can confirm this assumption. The next priority should be to get EMS providers into the scene quickly and safely into the newly created “warm zone”.

Whether it is an MCI, motor vehicle accident, haz-mat spill, or active shooter incident, scenes rarely go from a “hot zone” ( DANGER- do not enter) to a “cold zone”(ALL CLEAR) in a short time frame. More times than not, there is a “warm zone” time where the danger is mitigated, but there is still a remote possibility of a threat. What is being proposed and implemented in several EMS systems is a more integrated and “forward leaning” EMS response to active shooter incidents. In this model, the EMS team is safely staged very close to the crisis site and ready to “spring into action” on a moments notice. They should be lightly outfitted with trauma focused medical equipment in a decentralized arrangement (more on this later) and be set up for triage and emergent treatment of the victims. The law enforcement side should have a dedicated unit that is responsible for escorting and protecting the EMS team while they are in the “warm zone”. The concept can be viewed as another layer of personal protective equipment (PPE) for EMS providers. The law enforcement team makes sure that no “two legged threat” interferes with the EMS functions. In several full scale active shooter exercises, it was discovered that once the scene was relatively secure, that the law enforcement members were able to be utilized to assist the EMS team as long as the potential threat sources were covered.


EMS providers are generally well trained and proficient at responding to an MCI. An active shooter EMS response should be looked at like any other traumatic MCI. There may be a few specific common injury patterns to be expected: gunshot wounds, fractures and cuts (jumping out of windows) are the most likely types of injuries.

Training with law enforcement is critical to the success of an EMS response to an active shooter incident. As one Homeland Security expert stated, “You don’t want to be exchanging business cards on the day of the event.”

Now I want to be clear, I am not talking about being a “SWAT Medic” or “tactical medical training.” Tactical medicine is a specialized and highly discriminating endeavor. Tactical medics have the primary responsibility to take care of the SWAT team and are generally not well prepared for an MCI situation. Clearly, any tactical medic attached to a law enforcement team would be an integral liaison to the EMS personnel on scene.

We are talking about standard fire-based and private EMT’s and paramedics who find themselves staged and are preparing to enter an MCI, active shooter, barricaded subject or other law enforcement action incident.

The training “in-house” for EMS should include a review of MCI procedures. In an active shooter situation, there should be a balance between triage only, vs. emergent treatment on scene. If there are only a few victims and EMS resources are not stretched, them more focus can be placed on treating and stabilizing the patients before extrication and transport. If the numbers of victims far outnumber the rescuers, then a more traditional triage approach may be preferred.

There is also a school of thought regarding a revised approach to medical equipment. In this new model, each medic carries a belt pack or small backpack with at least the following items: several changes of PPE, triage tags/tape, or triage lights, trauma shears, stethoscope, head lamp, tourniquets, Asherman (or similar) open chest wound seals, OPA/NPA, Israeli dressings, quick clot dressings and roller gauze, and large trauma dressings. This provides for a more decentralized medical gear approach.  Each medic can operate independently and manage a trauma victim, at least initially. This gear can also be pooled according to emerging needs. Additionally there should be one or more “mother lode” packs with additional supplies including those already mentioned as well as several “roll up” tactical stretchers. Other items to be considered include basic O2/ advanced airway supplies, IV fluids and equipment, and even a few frontline meds/monitors. Even though the kit should be trauma focused, some victims may have true medical problems such as stress-induced asthma attacks, chest pain or other scenarios. The emphasis should be on trauma but medical problems do occur.

Figure 3. EMS personnel using a small, self contained medical kit for an active shooter/ MCI training scenario.

This new model stresses the adage of “light is right” and “speed saves.” The medical team must balance the urge to carry “everything” which may inhibit a fast, flexible and effective response versus a smaller med kit to deal with trauma only. Training and exercises will help determine the best course of action regarding medical kits.

Training events such as Urban Shield (www.urbanshield.org ) stress the importance of EMS and law enforcement integration. Urban Shield, sponsored and organized by the Alameda County Sheriff’s Department, is an annual exercise that is scenario based and includes up to 30 checkpoints that SWAT teams rotate through continuously over 48 hours. Some of the scenarios include an EMS, MCI, WMD, Haz-mat or other focus where respective agencies and disciplines integrate with the competing SWAT teams for a more realistic training platform. Funding is provided through various sources with the Urban Area Security Initiative (UASI) is the primary financial supporter.

Figure 4. Law enforcement providing protective cover for EMS in a “warm zone” active shooter scenario

The continued success of Urban Shield has other cities and countries committed to duplicating the concept and customizing many of the scenarios to address the local needs, critical infrastructure and vulnerabilities of their particular location. Currently Boston, May 2011- (see www.bostonurbanshield.org for more information) Seattle and Denver are in various states of planning for a similar event. EMS integration is a critical component of all of these venues.

The Active Shooter Response

Law enforcement has an aggressive approach to an active shooter incident. Local police realize they can no longer wait for the SWAT team. The current standard and widely accepted approach is to immediately go toward the crisis site/shooter with whatever resources are on hand. Even if there are one, two or three disparate law enforcement officers (for instance, an off duty officer dropping a child off at school, an armed security officer and a local officer) they make a quick plan, call for backup and go to the sound of shots fired. They are looking to engage, distract and hopefully neutralize the threat. In the meantime, other forces begin to muster and stage outside. This includes a variety of law enforcement, fire departments and other EMS assets.

Ideally a quick command post that embraces the concept of “unified command” is set up. This should include law enforcement, Fire, EMS and an agency representative who is familiar with the inner workings, layout and procedures of the facility/ workplace. EMS should have a “light, lean and ready” squad of mixed EMS professionals. They should be “forward leaning” and have good communication with the unified command. Law enforcement should have a protective detail identified and tasked with escorting EMS personnel.

Prior to EMS entry, law enforcement should give a briefing to EMS about the “dos and don’ts”; chain of command, emergency egress, room entries and communication. The EMS crew should also be prepared to split up if necessary. The exact number and ratio of law enforcement and EMS personnel need to be thought out by each agency and adjusted during training opportunities. Also, the nature of the event, available resources and other factors will dictate the exact ratio and numbers as appropriate. A recommended starting place for training is for 4 EMS providers and at least 4 law enforcement officers to make up the EMS response team.


Active shooter incidents rarely go from a “hot zone” to a “cold zone” quickly. Law enforcement officers know it is their responsibility to get into the crisis site quickly to distract, engage and hopefully eliminate the threat. EMS on the other hand is still waiting for the “all clear” and may be staged for minutes or hours; not willing, able or allowed to get in and start saving lives. Both EMS and law enforcement need to come together, train together and work together to better respond to these inevitable unfortunate incidents. We all know that bleeding eventually stops. Our job in EMS is to provide aggressive, safe and effective medical care while the patient is salvageable.

For more information, you can contact Jim Morrissey at jim.morrissey@acgov.org

Figure 5. Law enforcement and EMS work well together, especially if they train together in events such as Urban Shield.

NOTE: The list of medical equipment could be put into a side bar/ text box. This would include:

  • belt pack or small backpack
  • several changes of PPE
  • triage tags/tape, or triage lights
  • trauma shears
  • stethoscope
  • head lamp
  • tourniquets
  • Asherman (or similar) open chest wound seals
  • Israeli dressings
  • quick clot dressings (assorted sizes)
  • roller gauze/ ace wrap (assorted sizes)
  • large and medium sized trauma dressings
  • 1 and 2 inch cloth adhesive tape
  • note taking/ documentation material

Photograpy Credit for EMS images used in the Active Shooter Incideints and the Ems Response Article by Jim Morrissey / Josh Kennedy