Page 170 - Journal of Special Operations Medicine - Winter 2015

Operational Considerations and Guide for Active
Prior events also have demonstrated Shooter and Mass Casualty Incidents contain valuable
that civilian immediate responders information regarding additional operational and plan-
will often render aid to more seriously ning considerations. 5
injured victims. The role of immediate Education and Training
responders in providing immediate Central to the implementation of the concepts outlined
hemorrhage control cannot be in the Harford Consensus is the structured training of
underestimated and is a vital link in prehospital personnel in the clinical issues surrounding
the chain of survival for victims. EMS response to intentional events. The medical por-
tion of this training should emphasize the priorities of
care and immediate hemorrhage control, as well as rapid
emergency services agencies and is already used in nor- identification and correction of airway and breathing
mal daily fire and EMS operations. From operating on problems; it also should cover how this approach dif-
the scene of a motor vehicle crash on a busy roadway to fers from the conventional rescue ABCs (airway, breath-
offensive versus defensive firefighting tactics, risk-based ing, circulation). Personnel also should be trained in the
operations are common practice in emergency services. principles of self-care and buddy care.
Themes such as “Risk a lot to save a lot” are used to de-
pict the degree of risk tolerance that responders are will- Training initiatives should focus on the threat-based
ing to take. In Maryland, a statewide EMS protocol was dynamic nature of these incidents and the potential for
created to allow EMS personnel the necessary clinical the scene to change at any time. Comprehensive training
latitude to provide lifesaving interventions in potentially programs should incorporate immediate action drills to
volatile environments. Intended to be “all hazards” in ensure that essential skills of hemorrhage control are
4
nature and modeled after THREAT, this protocol incor- second nature. The concepts of hemorrhage control can
porates the best practices of Tactical Combat Casualty be easily integrated into mass casualty triage training.
Care and Tactical Emergency Casualty Care. The proto- In addition to robust initial training, the low-frequency,
col is threat-based in that the type of intervention to be high-consequence nature of these incidents makes it
provided is dependent on the proximity of the patient equally important to have ongoing training programs to
to the threat. help ensure that personnel retain these skills.

Various response models include the forward deploy- In addition to education and training for EMS personnel
ment of specially trained and equipped medical assets and professional rescuers, EMS agencies can incorporate
into the warm zone following active shooter/ intentional public-access hemorrhage control training into commu-
mass casualty events. Common examples include mixed- nity events, civic group meetings, and existing hands-
asset teams composed of law enforcement and medical/ only cardiopulmonary resuscitation training programs.
rescue responders. Personnel assigned to such teams
must be specially trained and equipped with ballistic
protection appropriate for entering these environments. The success of such programs requires
The success of such programs requires partnership and partnership and commitment between
commitment between EMS and law enforcement agen- EMS and law enforcement agencies
cies well ahead of an incident and should not haphaz- well ahead of an incident and should
ardly be implemented during the incident.
not haphazardly be implemented
Operational and incident command considerations in- during the incident.
clude early implementation of a unified command struc-
ture, designation of zones of operation, interagency and
mutual aid coordination, delineation of roles, and the Equipment
establishment of casualty collection points. In addition, An EMS system’s readiness to respond to active shooter
consideration should be given to how to incorporate and intentional mass casualty events necessitates rapid
the assistance of immediate responders, who can serve access to specialized medical equipment. This equip-
as force multipliers to assist in providing lifesaving in- ment includes, but is not limited to, hemorrhage control
terventions. Operational plans and any specialized re- devices, such as commercially available tourniquets and
sponse models must be exercised and critiqued to ensure hemostatic dressings.
that operational issues can be addressed and mitigated.
Resource documents such as the U.S. Fire Adminis- Customary practice for many EMS agencies is to cen-
tration’s Fire/Emergency Medical Services Department trally stockpile mass casualty equipment. However, given

158 Journal of Special Operations Medicine Volume 15, Edition 4/Winter 2015