Page 115 - Journal of Special Operations Medicine - Spring 2016

from, potential threats. That protocol also needed to The final product was presented to Governor’s Inter-
provide the clinical flexibility for certain circumstances, agency Active Assailant Working Group and included in
related to safety and operational constraints, when it the group’s final work product. This protocol, entitled
9
would not be possible to perform an intervention oth- “Potentially Volatile Environments with Life Sustaining
erwise considered to be standard of care. The prem- Interventions,” was approved for use by the Maryland’s
ise behind this protocol was to provide a mechanism EMS Board through Maryland Institute for Emergency
to allow EMS providers to approach these patients in Medical Services Systems and included in the 2015
a consistent manner that addressed the most imminent Maryland Medical Protocols for Emergency Medical
life threats, first based upon the provider’s proximity to Services Providers. As indicated by its title, the latitude
10
the real or perceived threat encountered, using a risk afforded by this protocol provides the clinical flexibility
mitigation model. As the protocol evolved, the commit- and adaptability for EMS personnel to deliver lifesaving
tee quickly realized the “all-hazards applicability” and care in a variety of real-world scenarios. The protocol
expanded value of the “warm-zone” concept to other represents one of the first statewide EMS protocols to
incidents including (but not limited to): address the threat-based need for mainstream prehospi-
tal EMS personnel to be able to render care under such
• Active assailant (active shooter/improvised explosive circumstances (protocol follows the references).
device) and other dynamic situations
• Postblast detonations Disclosures
• Industrial accident/explosion/fire
• Structural collapse/urban search and rescue situations The authors have nothing to disclose.
• Transportation mishaps with limited scene access
• In the immediate aftermath of a natural disaster such Acknowledgments
as a tornado
The authors wish to acknowledge Mr Michael Deckard
After reviewing the scientific literature as well as best and Mr Geoff Shapiro for their assistance.
practices guidelines, including those from the Commit-
tee for Tactical Emergency Casualty Care, the US De- References
6
partment of Defense Committee for Tactical Combat
Casualty Care, and the Hartford Consensus, the sub- 1. US Fire Administration. Fire/emergency medical services de-
7
8
partment operational considerations and guide for active
committee’s work product was a clinical protocol for shooter and intentional mass casualty incidents. https://www
EMS personnel appropriate for the realities of a civilian .usfa.fema.gov/downloads/pdf/publications/active_shooter
response environment. This unique prehospital proto- _guide.pdf. Accessed 23 February 2015.
col is threat based, meaning the type of intervention to 2. Jacobs LM, McSwain NE Jr, Rotondo MF, et al. Improving
be provided depends on the proximity of the patient to survival from active shooter events: the Hartford Consensus. J
Trauma Acute Care Surg. 2013;74:1399–1400.
the threat, the ability or inability to immediately extract 3. Levy MJ. Intentional mass casualty events: implications for
that patient to safety, and the risk/benefit of perform- prehospital emergency medical services systems. Bull Am Coll
ing an intervention in the warm-zone environment. The Surg. 2015;100(1 suppl):72–74.
concept of threat is dynamic and has the potential to 4. Maryland Institute for Emergency Medical Services Sys-
change at any time. Such rapid changes in conditions tems. MSP and MIEMSS convene active assailant working
group. Maryland EMS News. https://www.miemss.org/home
and the overarching need to evacuate personnel and pa- /Portals/0/Docs/Newsletter/EMS_News_Jan2014.pdf?ver=
tients may interfere with the delivery of the interven- 2014-01-16-101822-640.
tions directed within this protocol. A salient feature of 5. Maryland Institute for Emergency Medical Systems. EMS pro-
this protocol is that it provides latitude for the occa- vider protocols. http://www.miemss.org/home/EMS-Providers
sional, but not insignificant, circumstance when EMS /EMS-Provider-Protocols/EMS-Provider-Protocols. Accessed 23
February 2016.
personnel may inadvertently find themselves in a volatile 6. Committee on Tactical Emergency Casualty Care. Tactical
situation. Examples of this include, but are not limited emergency casualty care guidelines. http://www.c-tecc.org
to, domestic violence situations and other all-hazards /images/content/TECC_Guidelines_-_JUNE_2015_update.pdf
situations previously described. This protocol does not Accessed 13 February 2016.
replace or supersede the general patient care practices in 7. National Association of Emergency Medical Technicians.
Tactical combat casualty care guidelines. http://www.naemt
other sections of the Maryland EMS protocols, which .org/docs/default-source/education-documents/tccc/10-9
are still to be followed once the conditions resume a -15-updates/tccc-guidelines-for-medical-personnel-150603
routine level of operations. Of note, a separate tactical .docx?sfvrsn=2 Accessed 13 February 2016.
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tical EMS personnel who are trained and equipped to intentional mass-casualty events: the Hartford Consensus II.
Bull Am Coll Surg. 2013;98:18–22.
function as an embedded member of tactical LE team in 9. State of Maryland; Maryland Governor’s Interagency Active
direct-threat environments. Assailant Working Group. Guidance to first responders for

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