By WILLIAM FLETCHER
Scenario: You sit in quarters working on one of your shift’s many routine tasks. Suddenly, the dispatcher broadcasts the following alert message: “Engine 1, Engine 2, Ladder 1, Ambulance 1, Battalion 1: Respond to 123 Main Street, Central City High School, for report of multiple gunshots fired with numerous injuries.” A sudden adrenaline rush hurries you toward the apparatus floor. Your pulse quickens as you remember the images of numerous school crisis events that have occurred in the past few years, such as a high school student dangling from a second-floor library window trying to lower himself to safety as well as several law enforcement officers carrying a female victim across the lawn of a college campus. While responding to the location, you reflect on those previous events and ask yourself the following questions:
- What must I do to protect myself and my crew?
- Where should I stage, and where will I establish the triage, treatment, and transportation area?
- How many casualties can I expect?
- When and how will I assess, package, and remove casualties from inside the school?
- How long will that assessment or removal take?
- Most importantly, who will remove the casualties from the building to my triage area?
Each question is difficult to answer, compounded when you answer them on the day of the event. All of these operational issues require careful and deliberate consideration before an active shooter incident occurs. You can easily answer some questions if your agency conducts the necessary preincident planning. Such a plan should consider appropriate personal protective equipment (PPE) and defensive tactics prior to an active shooter incident. Determine the predesignated incident response points for a specific facility in advance. However, in most jurisdictions, you cannot answer the last four questions; you will not know the number of patients until the incident occurs. Undoubtedly, responders could better prepare if they had the most current population count for the facility in question. But predicting casualty numbers would be just that—a prediction.
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| (1) EMS members with SAVE gear and equipment. (Photos by author.) |
However, it is the final three questions that most likely pose a serious dilemma for most EMS providers reading this article. When and how will casualties inside the building be assessed? How long will those assessments and removals take? And who is going to remove the casualties from the building?
Since April 1999, I have actively developed and implemented emergency response plans for public safety personnel responding to school crisis and active shooter incidents. Throughout this planning process, we improved and refined several procedures and processes for our response. This planning effort also improved the relationship between school district administrative personnel and the public safety community. Although we have made great strides, it is still an area of concern: How do we provide rapid care and, more importantly, rapid extraction of casualties from the scene of an active shooter incident?
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| (2) A SAVE team makes entry into a school building. |
In February 2009, Boone County (KY) Deputy Sheriff Jerry Mitchum, the county’s special weapons and tactics (SWAT) team training officer, came to my office and began asking the questions that I posed at the beginning of this article. We discussed the provisions of the various active shooter and school crisis plans and admitted that there was indeed a deficiency. Mitchum then proposed an idea that evolved into what we refer to as the swift assisted victim extraction (SAVE) program. This program consists of training, equipment, and tactics and integrates EMS providers and law enforcement personnel to rapidly assess, treat, and remove casualties at an active shooter incident. In essence, the program allows EMS providers to alter outcomes for casualties who would very likely succumb to their injuries without timely treatment.
EMS personnel training distills military casualty management techniques, including triage and forward casualty collection points, and uses tactical and military casualty equipment to address life-threatening airway issues, severe hemorrhages, and patient movement. The program gives EMS providers specific instruction in tactical movement. The program is designed to allow EMS providers to effectively manage what is a new and different kind of immediately dangerous to life and health (IDLH) environment.
Nearly all law enforcement agencies across the country have adopted some variance of the quick action deployment (QUAD) response protocol. QUAD protocol implementation resulted directly from the Columbine High School shooting. Following Columbine, law enforcement officers (LEOs) could not simply establish a perimeter and wait for a SWAT team to arrive if they wanted to protect the public. Many within the profession determined that they required a new protocol and developed the QUAD protocol for LEOs arriving at the scene of an active shooter or crisis event. The first several LEOs form into a QUAD team and then deploy into the facility to address and confine the threat. Because of the assignment’s nature, these LEOs cannot stop and render aid to casualties they may encounter. However, the SAVE program provides those casualties with a chance to survive.
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(3) Law enforcement officers provide cover while EMS treats a casualty. |
As the QUAD team moves through the building, it can provide casualty locations to the LEO branch supervisor or dispatch center; this is the first step in the SAVE process. Once QUAD provides casualty locations to the unified command staff, Command can decide where to send the SAVE team. The SAVE program’s implementation is even more crucial, because in most jurisdictions the activation and subsequent deployment of a SWAT team will not take place until the incident is well underway. This delay loses valuable time that can cost lives if your agency waits until a SWAT team clears a building or relies on the team to remove casualties.
The SAVE program consists of the following steps. Once available, a minimum of four LEOs are sent to the SAVE entry point to provide security. Once the entry point is secure, the SAVE team’s EMS component is called to the location. In our jurisdiction, this component consists of the first engine company and ambulance (a total of five personnel). The EMS providers assigned to this group must complete SAVE training and be equipped with the necessary SAVE equipment and PPE (see equipment list).
Once formed, the SAVE group approaches the inner perimeter of the building. The majority of the SAVE group’s EMS personnel will approach the inner perimeter in an ambulance. One EMS member will drive the engine into the inner perimeter, parking near the building’s entry point. Three EMS personnel join the SAVE team’s four LEO members and enter the building as a team. The two remaining fire/EMS members deploy all needed equipment (SAVE equipment bag, patient movement equipment, etc.) from the SAVE transport ambulance at the entry point and then move the ambulance away from the building to a safe staging area within the inner perimeter. The SAVE team then performs its required functions.
As the SAVE team evacuates casualties from the inner perimeter of the building, the SAVE transport ambulance will approach the entry point to transport the casualties to the designated triage, treatment, and transportation area (EMS T3). If the SAVE team deems it necessary, it may establish a forward casualty collection point within the building or near the initial entry point, which may require rotating the EMS personnel within the SAVE team or the establishment of a second SAVE team to enter the building for casualty treatment, evacuation, and transportation to the EMS T3 area.
There are two important points to emphasize with respect to this program. The SAVE team’s LEO component has several priorities, but EMS provider safety is paramount. At no time during the process should EMS providers be without security. The hierarchy of the LEO priorities is the safety and security of the EMS providers first; LEOs will put themselves, their body armor, and their weapon system between the EMS providers and any threat. Their second priority is their own safety and the safety of the other LEOs.
The next point of emphasis is the end result. No matter what the crisis or evil that the perpetrator causes by injuring or killing innocent civilians (most likely children), if you can save even one casualty who may otherwise have succumbed to his injuries, then you have won.
The SAVE program allows EMS agencies to reduce risks to EMS personnel operating in a new IDLH environment, which is an unfortunate product of our evolving society. Over time, public safety agencies have identified IDLH environments (confined spaces, hazardous materials, and even structure fires) and managed the risks to personnel through equipment, training, and tactics. The SAVE program provides the appropriate training and tactics and recommends the appropriate equipment for your department to manage the risk posed by this new IDLH environment.
Over the past few months, several Boone County public safety agencies have trained to use the SAVE program. Our goal is to have countywide implementation by the summer of 2010. As I attend and participate in these training sessions, I have been very encouraged to see EMS providers and law enforcement officers meld together seamlessly into SAVE teams. Don’t wait until the day an active shooter incident or school crisis occurs to plan your response.
WILLIAM FLETCHERis an 18-year fire service veteran; a deputy director of the Boone County (KY) Office of Emergency Management; and a captain with the Hebron (KY) Fire Protection District, where he serves as a shift commander. Fletcher is an instructor in the fire/rescue science program within the Kentucky Community and Technical College System and is the equipment and training officer for the Northern Kentucky Regional WMD/hazardous materials response team. He also is one of 774 emergency management professionals worldwide with a “certified emergency manager” designation, conferred by the International Association of Emergency Managers. He has a degree in business administration with an emphasis in management.
