The scene of the Januray 2011 Tucson, Arizona, shooting. One of the victims was Gabby Giffords, who survived a gunshot wound to the head. (Photo courtesy of SearchNet Media.)
By Chris Lorenz
It is 12:15 a.m. and you’re just getting back to the station from a motor vehicle collision on the freeway. Another typical night. Calls are tapping out just far enough apart to make sure you do NOT get a solid stretch of sleep. Tonight will be no different; everyone is racking out. The captain decides the report can wait until morning. It’s lights out in the dorm.
Then, tones break and the lights come up. Just for a brief moment you thought you’d slept for several hours only to look at your watch and realize it has been 15 minutes since your head hit the pillow. You utter a few expletives and hear only the last bit of the dispatch. The whole house is rolling for a shooting at a low-rent apartment complex. You feel a little better about getting up knowing that the truck and battalion chief (BC) won’t be doing the “trucky” rollover. Misery loves company.
You have been to this location countless times for overdoses, domestics, and fires. As the last bay door opens, dispatch updates that law enforcement has multiple units responding, and multiple calls are being received reporting multiple victims. En route to the incident, the medic unit checks the status of the trauma centers. The BC confirms the number of victims with dispatch, believed to be three or four at this time. He requests an additional three medic units and two additional engines.
Law enforcement arrives on scene and calls for fire priority. They confirm three victims and one deceased. The police sergeant requests fire to contact him on LEARN (a shared frequency) to establish unified command. He advises the BC to meet him in the parking lot across from the south east entrance of the complex. The BC notifies all incoming units of the command post (CP) and staging locations.
The sergeant and BC meet face to face in the parking lot as the engines, medics, and trucks arrive. The sergeant tells the BC that his officers have chased what they believe to be a single gunman with an accomplice into the woods on the northwest corner of the complex. He has declared the entire complex a warm zone for operations and has four officers available for escort. Access into the apartment is tight, and it would be best to have everyone ride a single medic unit in and bring patients out to the CP.
The firefighters have donned their plate carriers and grabbed the red bag off the BC vehicle that contains four transport chairs and two trauma bags, each containing two tourniquets, five six-inch elastic bandage wraps, 10 rolls of gauze bandage, two space blankets, and a few assorted items pertinent to warm zone care. I do not advise bringing any unnecessary equipment into the warm zone. Speed is our friend; we only treat immediate life threats we can fix, and then we remove the patient. Guys also took tourniquets and pressure dressings from the rig’s trauma bags and stuffed them into their pockets.
Command combined nine arriving firefighters (three with the engine, two from the medic, and four from the truck) with four police offers (our escort) to form a rescue team. We loaded onto the medic unit and were escorted into the scene. Access to the complex is difficult on a good day, but on a weekend night the residents park on both sides of the street, making it barely passable for a patrol car (let alone fire apparatus).
The rescue team arrived at the ground-level apartment near the back of the complex, where there were numerous officers. Inside, officers pulled security and rendered some aid. There had been a party in this unit that turned violent when the resident of the apartment would not allow several men to come into the party. They left and returned with hand guns and knives.
There was a deceased male laying in the middle of the living room floor; his injuries were incompatible with life. An officer was holding direct pressure on a neck wound in the corner of the living room; he had also placed a tourniquet on the patient’s right leg, which appeared to be bleeding.
As you approach the officer, you see a male leaning against the wall in the kitchen who has what appears to be a chest wound and is struggling to breathe. The other team members followed the officer down the hallway and into a bedroom where a female was bleeding from her left arm; she had a tourniquet on that arm above the elbow and was also struggling to breathe. It was hard to visualize the injury because she was wearing a dark hooded sweatshirt. She also had a tourniquet on her right thigh, which appeared to be effective.
This run was just another Saturday night gone bad. Several victims had injuries that required immediate transport for quick surgical intervention. Considering the number of members on the rescue team, the math was on our side tonight. There is never a reason to “stay and play” with trauma.
We rapidly assessed the victims, treated life-threatening injuries, and packaged and removed victims from the “X.” If bad things happened once on the “X,” they can happen again; best not to be around when it happens.
An officer was holding direct pressure to the neck of one patient; although the leg wound was still bleeding despite the existing tourniquet. A quick assessment determined that it was tight, and there was a hand-width-sized amount of space between it and the groin area. We applied a second tourniquet in this space closest to the groin. As we tightened, the bleeding stopped. My partner pulled a roll of gauze and an elastic bandage wrap from the trauma bag while I assessed the tourniquet. He began applying the pressure dressing around the neck wound, which had drawn complaints from the patient (at least we knew the airway was intact). He reassures the patient that it is necessary to stop the bleeding, so he does what he can to calm the patient. Members roll out and place the patient on the transport chair. They wrap a space blanket around the patient to retain body heat, and they then carry the patient to the medic unit. The crew was able to sit the patient upright to place him on the bench seat.
The patient in the kitchen with the chest wound was still struggling to breathe. A quick blood sweep revealed a single hole on the right chest at about the nipple line. We felt air moving in and out of the hole and placed a gloved hand over it while we pulled, prepped, and placed a chest seal. We then rolled out and placed this patient on the transport chair. We also wrapped him in a space blanket and carried him to the medic unit. He, too, was able to sit, therefore we placed him on the bench seat.
The third patient’s blood sweep revealed she was bleeding above the tourniquet that was in place. Direct pressure was achieved by clamping around her upper arm until the tourniquet was ready. We placed another tourniquet at the crux of her arm, and the bleeding stopped spilling from the arm wound. The sweep also revealed a hole under the patient’s arm close to where the wound was. We placed a gloved hand is placed over it. Again, we pulled, prepped, and placed a chest seal; placed the patient on a transport chair; and carried her to the medic unit.
We assessed, treated and removed every patient in less than five minutes. The medic unit with law enforcement escort returned to the CP, where two additional medic units were waiting to receive patients.
This was not an active shooter/terrorism response; it was a Saturday night in an area to which fire and police frequently respond, often together. At its core, it was a response to a violent incident which was a basic trauma call. These allow us to master the basics, which makes us good under duress. It is why we run a lot of the cardio pulmonary resuscitation calls that we know are futile, but they are still good practice for when “game time” comes. If we practice our craft and treat our daily response to violence in this manner, it will just be an expansion of what we do every call so that when the “big one” hits, we will more likely be successful. The better we are at critical trauma care, the less time we spend in an area where bad things have already happened. This makes things better for everyone.
Tactical combat casualty care and tactical emergency casualty care concepts have become the standards of care in many jurisdictions. Adopting it is one thing, but practicing it is another. How often do you practice your rapid trauma or mass casualty care in a warm zone? By reinforcing the treatment life threats only, we can definitively treat and remove patients from the warm zone, where they can be better managed in the cold zone for treatment and transport. Our warm zone care consists of determining if the patient is alive or dead; if he is alive, does he have immediate life threats? Can we rapidly fix him? Can he walk, or do we need to carry him? Once we have exhausted our supplies or gone through every patient, we take out who we can and return for the rest.
Whether we are responding to a single patient or dozens of them, we must be cognizant of the lasting impact our initial actions will have at a shooting scene. We should also be cautious of what we say to potentially fatally injured people. Those who survive will most certainly recall your words. If, when removing patients, you can avoid taking them past the carnage they have not witnessed, it will be best for their long-term recovery.
Chris Lorenz has been in the fire service since 1998. He serves as member of the Pierce County (WA) Law Enforcement/Fire Joint Training Consortium, which has spearheaded the regional joint training & response to active shooter events for more than a decade as well as other cooperative operational and training objectives. Teaching at local, regional, state, and federal levels, Lorenz has served as a SWAT Medic since 2004. He has also been an instructor for the Puyallup Extrication Team since 2005.
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