The Medical Response to Armed Assaults
I discussed in the Dec. 3 Security Weekly how law enforcement agencies are changing their tactics to deal with armed assaults and how citizens can take steps to protect themselves in the event they encounter such a situation. But another critical component of the response to armed assaults lies in how to mitigate such attacks, an area to which the medical response is key. This includes the training given to law enforcement personnel, changes in the deployment of emergency medical service professionals and emergency room procedures. An additional lifesaving component comes in the form of new medical technologies made available to first responders and trauma centers.
Battlefield medicine has advanced a great deal over the past several decades, advances well illustrated during the U.S. invasions of Afghanistan and Iraq. Battlefield medical kits carried by combat medics and other soldiers have changed dramatically since 9/11. For example, when I was a young soldier attending U.S. Army basic training at Ft. Leonard Wood, Missouri, in 1983, the only first-aid kit issued to individual troops was a pressure dressing (though we were also taught some battlefield expedient procedures, such as using the cellophane wrapper from a cigarette pack with the pressure dressing to help seal a sucking chest wound).
By contrast, today’s soldiers carry an Improved Field Aid Kit (airmen and Marines carry something similar) that contains elastic emergency trauma bandages (a replacement for the old-fashioned pressure bandages), tourniquets, hemostatic combat gauze (gauze treated with a clotting agent such as QuickClot to stop bleeding) and an airway tube. These kits permit soldiers to administer first aid to themselves and others.
The same tools that have saved countless lives in combat in Iraq and Afghanistan are also now being issued to police officers inside the United States. Many officers carry these trauma medical kits in their squad cars along with smaller medical kits attached to their heavy raid vests. Police officers are taught how to use these tools to perform first aid on themselves and to administer aid to fellow officers and civilian victims. However, it is important to remember that in an active shooter situation, the primary focus of law enforcement efforts is to immediately engage the shooter to neutralize the threat and prevent further harm to victims. For police officers, first aid is only a secondary concern until the shooter is neutralized. Even so, the presence of first-aid kits with tourniquets and clotting agents at the scene of a shooting can mean the difference between life and death for a shooting victim who is bleeding out.
Emergency Medical Service
Not only have Emergency Medical Service personnel incorporated newer first-aid equipment developed for the battlefield, they have also changed their deployment tactics in active shooter situations. The April 1999 shooting at Columbine High School was a watershed event that changed the way police departments responded to active shooter situations. For EMS departments, the November 2013 domestic terrorism incident at Los Angeles International Airport, when an anti-government gunman shot and killed Transportation Safety Administration officer Gerardo Hernandez, was another watershed event.
In the Los Angeles airport shooting, first responders from the Los Angeles Fire Department were kept at a safe distance where they waited for the incident to be resolved before entering the shooting scene to render aid to Hernandez and the other victims. In fact, the police reportedly had to transport the wounded Hernandez to medical first responders in a wheelchair. The first responders rendered aid, but they were unable to save Hernandez, who had bled to death.
In response to this attack, the Los Angeles Fire Department has worked with the Los Angeles Police Department to change the way they respond to active shooters. Instead of setting up in a safe area and waiting for the incident to be resolved, they now coordinate with police officers to form rescue task forces designed to move medics to the scene in much the same way that combat medics work in a war zone.
As noted above, under active shooter protocols, the first police officers to arrive at the scene will rapidly form a team to engage the shooter. Officers who subsequently arrive will be deployed to form a perimeter around the scene and then render whatever other support is required. Now, one of these additional support functions is to join rescue task forces to escort medical first responders into the scene and protect them while they begin to administer first aid and evacuate victims.
Firefighters and paramedics will be kept away from the “hot zone,” where the assailant is actually being engaged by law enforcement officers and where they could be shot. But efforts will be made to get them into “warm zones,” or parts of the scene out of the gunman’s line of sight and fire where there are victims requiring aid and evacuation. Rescue task force medics normally perform rapid triage in the warm zone and then attempt to stabilize and evacuate the most gravely wounded. Treatment of lightly wounded people can wait until the incident is resolved or until they can be transported to the cold zone.
Some medical personnel are sent to attend special tactical medic training that will teach them how to operate safely during dangerous events. This not only improves their response to active shooter events, it also enables them to support many SWAT deployments. These medics also participate in active shooter training with their police counterparts to practice forming ad hoc teams and deploying into warm zones. In many places, these tactical medics are provided with body armor and helmets for protection. In reality, however, it may take time to get specially trained tactical medics to a scene, just as it often takes time for SWAT teams to be deployed. Because of this, many fire departments and rescue squads are providing active shooter training to all of their firefighters and medics in the same way that most police departments provide active shooter training to all of their officers. This way, the first fire and rescue units to respond can quickly work as part of rescue task forces.
According to a 2012 study by Johns Hopkins University School of Medicine, hospital based shootings are rare, but recent attacks in Mississippi, Pennsylvania, and California and non hospital gun violence in places like Colorado and New York can attest to the number of lives affected by these deadly events. With each devastating occurrence, we ask the same questions:
Why did it happen; could we have been better prepared; and how do we prevent it from happening again?
While predicting such events is nearly impossible, being prepared is not. Security experts from the Department of Homeland Security, various law enforcement agencies, and the International Association of Healthcare Security and Safety (IAHSS) have noted some key recommendations to guide hospitals in preparing an Emergency Action Plan (EAP) for an active shooter event.
Conduct an assessment.
An independent and realistic security assessment of your location can determine the facility’s possibility for an active shooter. An independent assessment can lend a new perspective to a location’s vulnerabilities.
Identify evacuation routes.
Establish variable escape routes, including final destinations once outside, and practice evacuating each route. Multiple routes can help if the shooter is familiar with one. Avoid open spaces where possible, and locations that will trap you such as an elevator. Prepare a safe hiding place. If evacuation is not possible, train staff to find a place to hide where the shooter is less likely to find them. The best location would have thick walls, few windows, a solid door and reliable communication capabilities such as a telephone, cellular phone reception or a duress alarm button. Instruct employees to lock and block the door with heavy furniture, cover all windows, turn off all lights, silence any electronic devices, lie on the floor and remain silent.
Establish an effective access control system.
Limit the number of entrances into the facility and install alarms and cameras on all doors. Consider restricting access to certain areas and educate staff to not prop doors open and to report individuals who enter without credentials.
Participate in an Active Shooter Drill
The Hospital Association of Southern California will host an Active Shooter Drill for health care Professionals. Experience a simulation of an emergency in a clinical and office setting. Hospital and community stakeholders including security, emergency room and nursing staff, human resources, risk managers, social workers and administrative personnel with an interest in minimizing the effects of workplace violence or an active shooter event are invited to attend.
Maintain facility wide communication.
Real time communication systems are essential for warning employees, patients and law enforcement of an emergency event. Test the communication capacity regularly and review your contact list to ensure you have included everyone. Train staff to work with law enforcement.
For an effective response and to avoid mistaken identity, instruct employees to follow the instructions of law enforcement implicitly. They should not move too quickly, and keep their hands visible and empty to avoid being perceived as a threat. Remember, law enforcement’s first priority is to neutralize the situation, not to help your staff or anyone else who may be injured.
To maximize response time, speak to outside response partners such as 911 operators or law enforcement in plain language.Avoid codes or jargon that only members of your hospital may understand.For example, instead of stating “We have a code silver in the ICU,” state “We have an active shooter in our Intensive Care Unit located on the third floor of our hospital’s west wing.”Keep it simple. Make sure the plan is easy to understand and follow in an emergency. Quick, effective decisions on the safest course of action could mean the difference between life and death.
As a last resort or if your life is in imminent danger because neither evacuating the facility nor seeking shelter is possible, disrupt and/or incapacitate the active shooter by throwing objects, using aggressive force and yelling.
Practice your plans, correct any deficiencies and practice again. It is extremely important for individuals to be trained so they can react appropriately if confronted with an active shooter situation. Training and education should render responses intuitive.
Draw on the expertise of both your staff and organizations such as the California Hospital Association, Hospital Association of Southern California, International Association of Healthcare Security and Safety, and American Society of Industrial Security. These organizations are sources of free and low cost best practice materials, trainings and seminars, and practice drills. A recommended resource is the Department of Homeland Security’s IS 907 – Active Shooter: What You Can Do.
IAHSS: Do Your Part to Prevent Hospital Gun Violence Healthcare Facilities, Police Grapple With Prisoner Escapes
How Not to Handle Forensic Patients Healthcare Facility Public Safety – Related Deaths Reached All – Time High in 2012 Daniel J. Holden serves as the Director of Healthcare Services for the Southwest Region of AlliedBarton Security Services where he helps coordinate the development and implementation of security and emergency management programs. He also chairs the Hospital Association of Southern California (HASC) Security and Safety committee and co-wrote the hospital emergencycodes to be compliant with the National Incident Management System (NIMS).
Kelly, Raymond W.
Active Shooter Recommendations and Analysis for Risk Mitigation ,2012 Edition. New York Police Department
Federal Emergency management Agency.
Active Shooter: What You Can Do: Instructor Guide , March 2012
International Association for Healthcare Security and Safety.
Security Design Guidelines for Healthcare Practices. 2011. U.S. Department of Homeland Security.
Active Shooter: How to Respond . October 2008.
Photo: Ed Santos