1. INTEGRATED POLICE / FIRE RESPONSE
RAPID RESPONSE TREATMENT MODEL
INTEGRATED POLICE / FIRE RESPONSE

2. Why Are We Here

3. What We Know 1949 - present Howard Unruh: Camden, NJ
2010/2012 record year in AS events (24)
2014 exceeding 2012
98% male, single attacker, daytime
Average number of deaths = 3.5
Average number of wounded = 4.8
80% rifle/shotgun / 75% multiple weapons
Rarely take hostages or ambush
Focused on high body count

4. What We Know Time & Intensity 1966 – 1999 85% over in under 12 minutes
2007 – Highest numbers of incidents
2nd Shooter?

5. Location of AS Events Schools = 24% Office Building = 11%
Open Commercial = 24%
Factory/Warehouse =12%
Other = 29%
Places of worship on the increase since 2010

6. Response Influence
84 % of incidents were over prior to police Interceding.
42 incidents police actually arrived in time to interrupt the shooting
Increased LE tempo
suspect lethality time?
victim count?

7. Time… …the precious commodity
2 min notification to 911
1.5 min to dispatch
POLICE / FIRE TIMELINE BEGIN
2.5 min response time
4 min insertion time
10 min-verify/mitigate shooter(s)
22 min prelim EMS introduced
33 min to introduce full EMS
<33 minutes

8. Need to Change Recognizing the need for change
Journal of Emergency Medical Services
International Association Fire Chiefs
International Association Police Chiefs
International Association Fire Fighters
Hartford Consensus Paper
Federal Emergency Management Agency
Tactical Emergency Casualty Care

9. National Center for Disaster Medicine and Public Health
Spring 2013
Role of Tactical EMS in Support of Public Safety and the Public Health Response to a Hostile Mass Casualty Incident
“It is unlikely that any single component of the public safety infrastructure will be able to effectively and comprehensively
respond to those threats posed and casualties inflicted during a hostile mass casualty shooting incident. Despite the
impact of tactical medicine, there is an urgent need for greater cooperative planning, education, and training among
law enforcement, fire, EMS, public health and the emergency health care system to develop enhanced preparedness for and response to these types of incidents.”
Dr. Nelson Tang, Department of Emergency Medicine,
Johns Hopkins University

10. WDMET Study Wound Data and Munitions Effectiveness Team
Vietnam,
7,989 patients
Ground combat

11. Injury Site

12. Fatal Injury Sites

13. WDMET Study & Time 90% of deaths occurred prior to definitive care
42% immediately
26% within 5 minutes
16% within 5 and 30 minutes
8‐10% within 30 minutes and 2 hours
Remainder survived between 2 and 6 hours during prolonged extrication to care
Only 10% of deaths occurred after intial care was intiated
Greatest opportunity for life saving intervention is early on

14. Time Counts! Era Survivability WWI 30% WWII 60% Korea 70% Vietnam 80%
Gulf War 90%
War on Terror 95-98%

15. Trauma Study Orange County, CA
Level I Trauma Hospital
14 years:
19,167 cases
Blunt and penetrating trauma
Results:
Increased mortality rate with scene times ≥ 20 min

16. What is Our Goal? Data driven answers:
Access patient as quickly as possible
Address critical-fixable injuries
Get patient to definitive medical care ASAP

17. Our Response
“Everything in war is simple, but the simplest thing is difficult.
The difficulties accumulate and end by producing a kind of
friction that is inconceivable unless one has experienced war.”
Carl Von Clausewitz

18. Current EMS Response Fire/EMS on an adaptation spectrum
Waiting for “all clear”
MCI protocol begins?
Forms of Tactical Medicine
TEMS, TCCC, SWAT Medic, Rescue Teams

19. Zone Response The Principles Hot Zone: Exclusion Warm Zone: Reduction
Cold Zone: Support
The Problem:
#1 most common A.A. item
Causes a progress friction point
Fire/EMS is waiting for the “all clear”

20. AS Response Models Rapid Response and Treatment Model (R2TM)
Rescue Task Force (RTF)
Advance Active Shooter Scenario (A2S2)
3Echo
Don’t confuse models with medical practices
TECC, TCCC, TEMS

21. Triage Identifies the number and severity of patients
Categorizes victims according to severity
Green, Yellow, Red, Black
Funnel Principle
Treatment
Transport

22. Systemic Problem-Solving
A combined effort putting the caregiver at the patient’s side within minutes of wounding to maximize life saving
Agency expertise
Clearly defined roles
Familiarity
Simplicity
Unification of Command

23. Engineer the Response
Embedded “Warm Zone”

24. Swim Lanes

25. Foundation 3 Tenets: Rapid LE response
EMS securely introduced into a warm zone
Rapid treatment and transport of the victims
Keep closest to normal SOPs

26. Police Response Response Assessment Security Rapid Response Tactics
Threat mitigation
Initiate Sergeant / Battalion Chief link-up
Assessment
Establish foothold (FOB)
Identify Casualty Collection Point (CCP)
Security
Internal / External security
Police bring wounded to CCP
Introduction of Fire EMS

27. Response Immediate introduction of LE assets
Uniformed vs Plain Clothes?
Move quickly to last known area of suspect / verification?
Understand “sweeps” vs “clears”
What are immediate threat indicators
Decentralized tactics are ideal
FOB’s can be useful

28. Threat Mitigation
Does not require 100% confirmation of suspect location
Fled, Dead, Captured
Once Immediate threat indicators have lapsed, transition to victim assessment / retrieval
Can continue sweep operations and CCP identification

29. Unification of Commands
Paramount!
Needs to be physical is design
Sgt / BC ideal
Fire Understands / Police need to embrace and execute
Only one location for UC.
Don’t view UC as a monolithic entity
2 key joint-decisions will need to take place in <15 minutes

30. FOB Purpose Brings stabilization to operations
Provides for dual operations
Aids UC and point of contact on interior
Increases efficiency of interior sweeps
Aids with decentralized tactics

31. The Casualty Collection Point
Provides a bridge between police and fire
Allows for simultaneous operations
Proven military tactic for categorization
Minimal UC Command & Control
Multiple CCPs?

32. CCP Location Key Elements
Law Enforcement Identifies
Fire Establishes
Not necessarily victim dependent
Ease of vehicle access / transport priority
Ability to Secure
Adequate Space
Should be located on the interior
Can have Multiple CCP’s
Can establish CCP with barricade / hostage

33. Corridor Lockdown When immediate threat indicators have subsided
LE lockdown hallways, architectural features, large geographical areas
Sets the stage for victim transfer
Corridor lockdown builds on itself
Aids in scene stabilization

34. Why Have LE Transfer Victims?
Instinctual
Economy of force
Continual sweeping does not actively aid victims
Resource driven

35. Hot Zone Medical Care Limited to rapid and easy intervention
i.e. Tourniquets
Victims transferred to CCP
Hasty field triage
Get critical patients to EMS first

36. Tourniquet Use 50% of all combat deaths are hemorrhagic
20% of hemorrhagic deaths could have been controlled with pressures
80% require surgical treatment
Does not increase the loss of limbs

37. Fire/EMS Response Stage Link-Up Enter Warm Zone Out of line of sight
Prepare for response entry
Link-Up
Establish Unified Command
Security escort
Enter Warm Zone
MCI protocols

38. Fire Response Fire to respond to a staging location; not incident
Gather appropriate information
Number/type of patients, threat type
Order resources early
Ambulances, manpower
Communications Center to patch channels or assign a mutual channel

39. Fire Stage Out of line of site Assign staging location
Establish command location
First arriving apparatus to keep overheads on

40. Command Link-Up Request link-up over patched or mutual channel
Location to be out of hazard zone
Capable members
Fire: officer, BC, Chief; LE: Sgt, Lt., Commander
Should be physical
Cautious of non-physical link up
Simply ICS structure if possible

41. Communications Plan LE uses assigned frequency for threat mitigation
Simplex to be used if comm. problems
Fire/EMS responds on patched channel
Once MCI determined, request additional channel
All fire/EMS operations occur on additional channel

42. Components of Fire Security
Apparatus Security
Escort
On Engine
NFPA Guidelines
Overwatch
CCP Security

43. MCI Protocols within CCP
Triage and treatment occur
Separate treatment zones
Clean work space
Plan transport corridor/process
Patient to ambulance
Ambulance to hospital
DO NOT delay transport of critical patients for non-critical treatments

44. Triage Group Identifies the number of patients
Categorizes victims according to severity
Green, Yellow, Red, Black
Determine categories
i.e. S.T.A.R.T, JumpSTART, SALT, ABC…
Funnel Principle
Will your triage process take too much time?

45. Triage: MINOR “Walking Wounded” Minor injuries
Can survive for days without treatment
Generally the largest category

46. Triage- DELAYED DELAYED Stable but will require definitive care
Require observation
Condition may worsen
Not Black, Red, or Green

47. Triage: IMMEDIATE Requires immediate attention Surgical room priority
First transported
Minutes Count

48. Triage: DECEASED Absence of breathing and a pulse
Undisturbed unless there is a need to move

49. Interference with Transport
Increase victim scene times
Increases total out-of-hospital time
Requires more resources
Creates damage

50. Destination Etiquette
Do not shift the MCI to another location
Refrain from blind transport (last resort only)
Assign someone to communicate with receiving facilities
Example: Medical Resource Hospital
Document as much patient info as practical
Use technology

51. Environmental Concerns
Stop further harm from occurring
What is the weather?
Keep in doors if appropriate
No return: 32*C / 89.6*F
Need for decontamination?

52. Fire Stage
LE Response

53. LE initial entry
Forward
Operating base
Casualty
Collection point S

54. LE victim
transfer S

55. FIRE
RESponse

56. Fire to
ccp S O O

57. Triage
grouping C M H T T

58. Victim
transport C M H T T

59. Dual Priorities Graph