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

Towards the Sound of Shooting

A new response to the active shooterBlake Iselin

Firefighter/Paramedic

Arlington County Fire Department

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

The Reality

WMD’s are hard to acquire

Expensive

Require significant resources and training

Larger chance of being detected

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

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

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.

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

Rescue Task ForceUse 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

RTF RTF MedicineMedicineWarm Warm

Zone careZone care

RTF MedicineThe 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.

RTF MedicineThe 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

RTF MedicineHow people die in ground combat

Bellamy, RF. Causes of death in conventional land warfare, Military Medicine. 1984

RTF MedicinePreventable causes of death

15% of Ground Combat Deaths are Preventable

RTF Medicine9% KIA Bleeding to death from extremity wounds

RTF Medicine9% KIA Bleeding to death from extremity wounds

Normal Normal Blood Blood

VolumeVolume

Death Death probableprobable

RTF Medicine5% KIA Tension pneumothorax

RTF Medicine1% KIA Airway obstruction

RTF MedicineWarm Zone care

Stabilize injured using SCAB-E assessment and treatment

Situation

Circulation

Airway

Breathing

Evacuation


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???Why do we use the Acronym : SCAB???

It is pointless to treat a casualty for a developing tension It is pointless to treat a casualty for a developing tension pneumothorax while he is dying by strangulation from a pneumothorax while he is dying by strangulation from a

compromised airway or by uncontrolled bleeding.compromised airway or by uncontrolled bleeding.


Secondary devices

Rapid triage/treatment of all victims in reasonable geographic area

Directed evacuation of those able to self evacuate

No CPR

SituationSituation


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

CirculationCirculation

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 usageCirculation - Tourniquet usage




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 DressingCirculation - Pressure Dressing


Certain types of life-threatening hemorrhage cannot be controlled by a tourniquet because of anatomical constraints.

Head, neck, and high groin area

Circulation - Hemostatic AgentsCirculation - Hemostatic Agents


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 AgentsCirculation - Hemostatic Agents


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

AirwayAirway


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

BreathingBreathing


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)

EvacuationEvacuation

RTF OperationsRTF Operations

RTF Operations

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

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

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.

RTF Operations

RTF Operations

RTF Operations

RTF Operations

RTF Operations

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


Fire/EMS CommandEnsure 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


Police CommandTrack 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

RTF CommunicationsFire/EMS

Stay on the Fire/EMS ops channel

Provide location of RTF

Number of victims

Additional RTF needs

RTF CommunicationsPolice

Stay on the police ops channel

Provide location of RTF

Location of additional threats

Any change to the security of the RTF

RTF EquipmentBallistic and Medical

RTF EquipmentBallistic

PPI level IIIA Hornet Tactical Vest

PPI level IV Rifle Plates (Chest and Back)

PPI level IIIA Special Ops. Helmet

RTF EquipmentMedical - 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

RTF EquipmentMedical - 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

RTF EquipmentMedical 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.

RTF EquipmentH-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

RTF EquipmentCelox Guaze

Various forms

Works in all temp ranges

Works on heparinized/coumadin blood

Can be used as a burn bandage

RTF EquipmentHalo Chest Seal

Two large seals

Gel based adhesive

RTF EquipmentNP and 14ga.

Questions?

Documents

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