Page 87 - JSOM Winter 2018

current national position papers and best practice guidelines. have skewed the results. Others might argue that, statistically,
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These guidelines have now become a national standard as 76% would be considered a very high response rate for a sin-
part of the National Fire Protection Association (NFPA) 3000 gle attempt at a paper survey for the sample size of our study.
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Standard for Active Shooter/Hostile Event Response (ASHER) From a statistical standpoint, using a 99% confidence level
Program. If these Urban Fire Forum and NFPA recommen- with a sample size of 515 and a response rate of 76% (n =
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dations are not adopted locally by an individual agency, then 391 responders), the margin of error is ±2.7%. Future studies
EMS and firefighters may never be willing to fully embrace should examine whether these results are reproducible in other
the RTF concept at the local level. This is especially important parts of the country or if regions with lower or higher rates of
because many active shooter incidents are not limited to large crime may influence the results.
cities; they also occur in smaller towns and cities.
A potential bias would have been for one individual to have
After policy and, in some states, regulatory changes, the cost filled out more than one survey form; this is unlikely because
associated with education and purchase of ballistic vests will there were monitors throughout the room, but it is not im-
be another barrier for EMS. However, if these barriers could possible. Another limitation with potential bias is participants
be overcome, we could save lives in an active shooter inci- anticipating this survey may be used to change public policy
dent that would otherwise be lost. Some may argue that the and thus may influence funding of ballistic equipment. If that
cost of ballistic equipment for EMS is prohibitive, yet some were the case, these individuals still feel the need to have the
researchers have shown that “retired” ballistic vests, ranging ballistic equipment. Some readers may contend that the will-
in age from 6 to 27 years, maintained their ballistic protection ingness of EMS professionals to respond is irrelevant because
against 9mm, .40 caliber, .45 caliber, and 12-gauge shotgun the policy of an EMS agency should exceed an individual’s
rounds. Those authors suggested that, in theory, retired bal- willingness to respond, while others would support that if the
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listic vests from law enforcement could be given to EMS as a majority of EMS professionals are unwilling to respond, then
first step in this otherwise costly process. Many will disagree the EMS agency would have difficulty implementing the policy
with these authors about having EMS and firefighters supplied or, worse, have a decreased retention of EMS personnel.
with used ballistic vests. Nevertheless, the study does show
that the typical ballistic vest has a much longer lifespan than Although the survey did not specify the exact type of ballistic
the 5 years suggested by the manufacturer; thus, over time, the gear, and that may have affected the results, we would expect
costs would be much less than expected. the EMS agencies to implement a best practices model and
provide wearable protection. We purposefully decided not to
The authors do support that EMS professionals be provided specify the type or level of ballistic gear in the survey, because
with ballistic gear but do not support EMS having a firearm. of the many different types and levels of ballistic gear avail-
We also support permitting only EMS professionals who are able, each with its own advantages and disadvantages. It is
sworn law enforcement officers or who are an active compo- possible that the willingness of EMS professionals to respond
nent of the responding SWAT team to carry a firearm, and may have varied if we had specified the type of equipment
then only if approved by the local law enforcement agency (e.g., vest, helmet, eye protection) and level of protection (i.e.,
and according to state EMS rules. Owing to increased violence level IIA versus IIIA versus IV).
against EMS professionals, some states have added or are con-
sidering legislation allowing EMS professionals to carry fire- Future studies should also compare the willingness of EMS
arms while on duty. Interestingly, 92% of survey participants providers to respond in an active shooter event if given only a
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were willing to respond if they had both ballistic gear and a ballistic vest versus a vest, helmet, and eye protection. Studies
firearm. Furthermore, our results suggest that tactical- or mili- also could be performed to determine the specific resources
tary-trained participants were 8.9 times more likely to respond needed by EMS providers to maximize survival of victims af-
if provided ballistic gear and a firearm, compared with those ter an active shooter event. Research on the ideal number of
without tactical or military training (95% CI, 2.1–37.8; p < personnel in an RTF to maximize survival has not been docu-
.001). This study was conducted in North Carolina where the mented, to our knowledge.
Rules by the State Office of EMS do not allow an EMS pro-
fessional to carry a firearm while on duty, which is in direct Conclusion
contradiction to the state concealed carry permit legislation
that allows permit holders who are firefighters and EMS pro- The first priority in any active shooter situation is to stop the
viders to enter a school with a concealed weapon when acting shooting, but a close second is to rapidly treat those casualties
in discharge of their official duties. 27 with life-threatening injuries to decrease the overall mortality
rate. The findings of this study suggest that if given ballistic
This study has several limitations. The survey was limited to gear, the majority of EMS professionals would respond to an
only one state, and most participants were paramedics. Al- active shooter incident if escorted by law enforcement as part
though the survey was performed at a statewide EMS meeting of an RTF. Most EMS professionals, if escorted by law en-
with participants from across the entire state, a substantial per- forcement as part of an RTF, would not respond if ballistic
centage (33%) of respondents had 20 years or more EMS expe- gear were not provided. It appears that a majority of EMS
rience, and 20% reported previous military or law enforcement professionals are willing to put themselves in harm’s way by
experience. As such, the willingness of EMS professionals to entering a warm zone as part of an RTF if they are simply pro-
respond to an active shooter incident may vary in other states, vided with the proper training and ballistic gear.
with different levels of providers and of experience.
Disclosures
Some may argue that our response rate for our survey was The authors have indicated they have no financial relation-
only 76%, and that missing 24% of the participants could ships relevant to this article to disclose.

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