1. Towards the Sound of Shooting A new response to the active shooter Blake Iselin Firefighter/Paramedic Arlington County Fire Department

2. The Reality Active shooter incidents happen everywhere in this country, from the small town to the largest cities Easy and effective Low cost Can be obtained easily

3. The Reality WMD’s are hard to acquire Expensive Require significant resources and training Larger chance of being detected

4. The Reality Police agencies have made signifiant changes in their response since Columbine and are extremely aggressie when responding to an active shooter Fire/EMS agencies have not, they still stand outside till the police have secured the entire building This leads to the injured not receiving treatment and dying from wounds they received

5. The Reality Fire/EMS needs to take a more progressive response and assume more risk to save lives. Risk is nothing new the the fire service, we are willing to enter a burning building, confined spaces, hazmat releases, etc. to save lives. The risk is mitigated by the use of SCBA, turnout gear, training, equipment, and SOP’s

6. The Reality In the active shooter incident the risk is mitigated with the use of ballistic gear, security, equipment, SOP’s and training. The environment in an active shooter incident is more controllable then that of a building on fire.

7. New Response Goals Provide rapid treatment to the wounded Prevent those who have survivable injuries from dying Use resources more efficiently and effectively Evacuate the wounded to definitive care sooner Provide the proper gear and security for the operators

8. Rescue Task Force Use the military medicine doctrine of Tactical Combat Causality Care (TCCC) Use both Police and Fire assets in the capacity that they are trained and equipped for Provide the proper PPE for those operating in the warm zone Drastically reduces the time till treatment of the wounded begins Able to treat a large number of victims with minimal resources

9. RTF Medicine Warm Zone care

10. RTF Medicine The Doctrine of Tactical Combat Casualty Care Following the SEAL casualties sustained during the invasion of Panama, the Navy Special Operations community conducted an extensive review of combat death and trauma care. The concept of TCCC is developed in 1996 after an extensive analysis of the Vietnam Casualty Database.

11. RTF Medicine The Doctrine of Tactical Combat Casualty Care Treat patient as quickly as possible at or near the site of wounding despite the still-fluid tactical situation. Use stop-gap measures at the site of injury to manage the preventable causes of death on the battlefield. Rapid evacuation from the threat environment to care

12. RTF Medicine How people die in ground combat Bellamy, RF. Causes of death in conventional land warfare, Military Medicine. 1984

13. RTF Medicine Preventable causes of death 15% of Ground Combat Deaths are Preventable

14. RTF Medicine 9% KIA Bleeding to death from extremity wounds

15. Normal Blood Volume Death probable

16. RTF Medicine 5% KIA Tension pneumothorax

17. RTF Medicine 1% KIA Airway obstruction

18. RTF Medicine Warm Zone care Stabilize injured using SCAB-E assessment and treatment Situation Circulation Airway Breathing Evacuation

19. RTF Medicine Warm Zone care Death from Hemorrhage ; 1 - 3 minutes Death from Airway compromise; 4 - 5 minutes Death via Tension Pneumothorax; 10+ minutes “Golden Hour” for Shock 60 minutes Why do we use the Acronym : SCAB??? It is pointless to treat a casualty for a developing tension pneumothorax while he is dying by strangulation from a compromised airway or by uncontrolled bleeding.

20. RTF Medicine Warm Zone care Secondary devices Rapid triage/treatment of all victims in reasonable geographic area Directed evacuation of those able to self evacuate No CPR Situation

21. RTF Medicine Warm Zone care Critical focus on stopping life-threatening bleeding Supported by combat data as most likely injury as well as most common cause of death Technique of choice is tourniquet Quick, effective, and easy to apply Multiple published studies show safety if removed in less than 2 hours Subsequent rx aimed at de-escalating from tourniquet Other option is pressure dressing with wound pack Circulation

22. Total or partial amputations Large deep lacerations or extensive tissue damage with heavy bleeding Massive arterial or venous bleeding When in doubt, tourniquet is placed Circulation - Tourniquet usage RTF Medicine Warm Zone care

24. Quick, easy to apply Designed to use mechanical advantage and elastic bandage to put direct sustained pressure over wound Must use packing for deep wounds Incorporates large absorbent dressing Circulation - Pressure Dressing

25. RTF Medicine Warm Zone care Certain types of life- threatening hemorrhage cannot be controlled by a tourniquet because of anatomical constraints. Head, neck, and high groin area Circulation - Hemostatic Agents

26. RTF Medicine Warm Zone care Hemostatic agents incorporate proteins or chemicals designed to initiate and accelerate the fibrin clotting process. When used with sustained direct pressure, hemostatic agents help to seal the damaged arteries and veins involved in uncontrolled hemorrhage. Circulation - Hemostatic Agents

27. RTF Medicine Warm Zone care Emphasis on basic airway skills Nasal trumpet placed on all patients with altered mental status Effective regardless of gag reflex Relatively stable once placed Stimulating to transiently unconscious patient Patients placed in recovery position or position of comfort while waiting evacuation Airway

28. RTF Medicine Warm Zone care Focus care for penetrating chest wounds Immediate application of occlusive dressing for any wound from umbilicus to trapezius Proactive needle decompression for any patient with thoracic injury and respiratory distress Breathing

29. RTF Medicine Warm Zone care Depending on the building, injured are evacuated to the CCP or cold zone Additional RTF’s needed Make use of surrounding resources (moving carts, wheel chairs, etc) Evacuation

30. RTF Operations

31. The RTF consists of 2 police officers and 2 medics Officers provide front and rear security and control movement Medics provide treatment and evac. of the wounded RTF operates in the warm zone

32. RTF Operations As the contact team moves through the building searching for the threat, location of wounded is relayed back to command After the contact team either neutralizes the threat or contains it the RTF is deployed RTF proceeds to the location of the wounded and begins treatment

33. RTF Operations The objective of the first RTF is to treat the wounded until they run out of equipment or run out of wounded to treat. Then they switch objectives and begin evac of the wounded. The second and subsequent RTF’s begin evac of those treated until the team ahead of them runs out of equipment and then they leap frog forward to finish treatment.

34. RTF Operations

39. RTF Command and Control These types of incidents are very dynamic and the number of threats, victims, etc can change at any time. The first Fire/EMS supervisor and the first arriving PD command officer need to form a Unified Command. The number of RTF’s formed is based on the availability of resources both FD and PD. The location of the CCP is based on the building type, number of victims, threat location, resources, and environmental conditions. Movement is controlled by the police element of the unified command

40. RTF Command and Control Fire/EMS Command Ensure adequate resources are available for the incident and number of victims. Track the location of the RTF’s through the building Track of the number of victims and their locations in the building Ensure the MCI areas are established and are supplied Ensure an equipment cache is available to restock the RTF’s and treatment areas as needed

41. RTF Command and Control Police Command Track the location of the Contact team(s) and location of the threat(s) Track the location of victims reported by the Contact team and deploy the RTF to those areas. Ensure adequate resources are available to suppress the threat and to staff the RTF Track the location of the RTF Share intelligence with the FD as part of the Unified Command

42. RTF Communications Fire/EMS Stay on the Fire/EMS ops channel Provide location of RTF Number of victims Additional RTF needs

43. RTF Communications Police Stay on the police ops channel Provide location of RTF Location of additional threats Any change to the security of the RTF

44. RTF Equipment Ballistic and Medical

45. RTF Equipment Ballistic PPI level IIIA Hornet Tactical Vest PPI level IV Rifle Plates (Chest and Back) PPI level IIIA Special Ops. Helmet

46. RTF Equipment Medical - Vest Mounted M.E.T Gen-III Tourniquet x 2 H-Bandage pressure dressing x 2 Celox gauze x 2 Halo chest seal x 2 NP airways x 2 14ga. 3.5” needles x 2 Tegaderms x10

47. RTF Equipment Medical - Jump Bag M.E.T Tourniquet x 6 H bandage pressure dressing x 6 Celox gauze x 6 Halo chest seal x 6 NP airways x 6 14ga. 3” needles x 6 Tegaderms x 20

48. RTF Equipment Medical Emergency Tourniquet Gen-III Lightweight. Does not need to be fully cinched tight before operating windlass. Aluminum Non-breakable windlass. Simple operation. Can be applied and secured in seconds.

49. RTF Equipment H-Bandage Easy to apply Large absorbent dressing Elastic ace wrap with velcro Easy to secure Ceramic H for mechanical pressure Well attached so may be used to fulcrum bandage for pressure

50. RTF Equipment Celox Guaze Various forms Works in all temp ranges Works on heparinized/coumadi n blood Can be used as a burn bandage

51. RTF Equipment Halo Chest Seal Two large seals Gel based adhesive

52. RTF Equipment NP and 14ga.

53. Questions?