Page 114 - Journal of Special Operations Medicine - Spring 2016

An Ongoing Series

A Threat-Based, Statewide EMS Protocol to Address
Lifesaving Interventions in Potentially Volatile Environments

Matthew J. Levy, DO; Kevin M. Straight, MS; Michael J. Marino, MS; Richard L. Alcorta, MD

ocal and international events of mass violence, in- and a follow-on LE officer. Jurisdictional variability ex-
cluding, but certainly not limited to, active shooter ists regarding the functional and medical capabilities of
L or active assailant situations, as well as dynamic these hybridized teams, as well as the degree of opera-
mass casualty events, have forced the emergency medi- tional risk tolerance to be taken on scene. Other pro-
cal services (EMS) community to rethink its response posed models include the use of primarily LE personnel
strategies to such events. The challenge for emergency to render patient care in this environment. The LE model
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personnel to access, identify, and treat those victims who requires ensuring personnel who may not have a primary
have potentially survivable injuries juxtaposes the tradi- medical role have the knowledge, skills, and ability to
tionally taught practice of waiting for the scene to be deliver lifesaving emergency medical care. To maximize
clear of all threats. Lessons learned from previous inci- responder safety and mission success, use of either model
dents have taught us that waiting for the entire scene to should not be an ad hoc or improvised on-scene deci-
be totally safe and without the possibility of continued sion. Rather, it requires partnership and commitment be-
threat will result in more lives lost. This urgency has tween EMS and LE agencies well ahead of the incident.
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altered the foundation from which conventional prehos- Preplans are necessary to ensure a mutual understanding
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pital EMS response and operations are based. Beyond exists regarding mission objectives, role, and responsi-
such intentional events, the same threat-based principles bilities of providers, as well as consensus on operational
guiding the timely rendering of lifesaving interventions procedures and medical care to be performed. Training,
apply to many other all-hazards incidents. This requires exercises, and drills should be used to accurately mea-
a fundamental change in how we in EMS think about sure and improve upon the response plan.
response to situations with the potential for continued
threat. In the wake of the tragedy that occurred in New Town,
Connecticut, the Maryland Governor’s Interagency Ac-
While it is no longer acceptable to wait for the scene to tive Assailant Working Group was formed with the in-
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be totally safe and clear of all threats prior to making tent to produce a guidance document for use by public
entry, law enforcement (LE) and EMS agencies should safety agencies across the state. This committee com-
have combined operational preplans and agreements prised local, state, and federal officials as well as sub-
that specifically address medical care as promptly and ject matter experts from academia. Early in the series of
as close to the point of injury as possible. These efforts meetings, it was identified that caring for patients fol-
must at all times acknowledge the safety of EMS person- lowing such events requires a change in the approach to
nel, and evaluate the risk versus benefit of their exposure general patient care as directed by the Maryland Medi-
to potential threats. It is also important to note that ter- cal Protocols for Emergency Medical Services Providers
minology such as “safe” from hazards versus “clear” of (a single statewide protocol for all EMS providers). A
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hazards can have different meanings and must be thor- medical subcommittee was created and tasked with re-
oughly discussed during the preplanning sessions. To ad- searching current scientific evidence and best practices
dress this challenge, various models of integrated medical from both military and civilian consensus guidelines for
response have emerged. One such model involves the use caring for casualties during these events.
of hybridized teams consisting of combined LE and EMS
personnel, often called a rescue taskforce, to access ar- The committee was charged with the development of a
eas of indirect threat. The conventional rescue task force unique EMS protocol for the administration of lifesaving
is composed of a lead LE officer, two EMS providers, interventions while in close proximity to, but protected

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