Download Active Shooter Training

Active Shooter / Mass
Violence Incidents
Region VIII EMS – September 2016
Objectives
• Definitions
• Statistics
• Injury patterns
• Treatments
Objectives
• Science of coagulopathy
• What is the role of the PD
• Four legged responders (K9)
• Post traumatic stress
Note
• Active shooter, Rescue Task Force, and
Tactical Emergency Medicine are in and of
themselves intensive subjects that require
multiple days of didactic and practical
training. This education module is designed
to touch upon those topics and provide some
general knowledge in each of the areas. It is
in no way wholly inclusive for any of these
subject areas and is not designed nor
intended to replace or replicate those training
regiments.
Active Shooter
• What is it?
“An individual(s) actively engaged in killing or
attempting to kill people in a confined and
populated area.”
Statistics
• FBI has identified 160 active shooter incidents between 2000 and
2013
Statistics
• On average 11.4 incidents annually
– 6.4 on average incidents between 2000-2006
– 16.4 on average between 2007-2013
• 70% occurred in commerce or educational
environment
• 60% ended prior to police arriving
Statistics
• Casualties
– 486 killed
– 557 wounded
• 64% of incidents considered “mass
killings”
– Defined as 3 or more killed
• 25% of incidents involve multiple locations
Shooters
• All but 2 incidents involved a single
shooter
• In at least 6 incidents shooters were
female
• 40% of shooters committed suicide
• 28% of shooters exchange gunfire with
police
Shooters
46.7% of officers that engaged the threat
sustained a gun shot wound…
Self Check
• Items to consider for your service area…
– How does a shooter in multiple locations
complicate department responses?
– How do officers racing towards the gunfire
change dynamics of response?
– If the location is a school vs. an office, how is
the emotionality of the response affected?
• What if it’s your child’s school?
What if this happened in your town?
How close is too close?
Notable Incidents
• Cinemark Century 16 Theater
– 70 (12 killed, 58 wounded)
• Virginia Tech
– 49 (32 killed, 17 wounded
• Ft. Hood Texas
– 45 (27 killed, 2 wounded)
• Sandy Hook Elementary
– 29 (27 killed, 2 wounded)
Century Theater Shooting
Century Cinemark Theater
• Aurora Colorado
• Active shooter in a crowded theater
• 70 victims total
– First officer arrived in 83 seconds
– First ambulance in 3 minutes
– First fire unit in 5 minutes
Century Cinemark Theater
Lessons Learned: What went well…
– Patient distribution to local hospitals
– Family reuniting center quickly established
– Psychological care for first responders
– All patients triaged and transported rapidly
– All patients that were transported survived
Century Cinemark Theater
Lessons Learned: Areas of improvement
– Communication
• Unified Command
• Fire Department Incident Command
• Fire Police Communications
Century Cinemark Theater
Lessons Learned: Areas of improvement
– Risk assessment
• EMS did not know shooter was detained
– Access to victims
• Medic units unable to get close due to congestion
• Transportation group never established
– Triage tags not utilized
• Difficulty in prioritizing patient transport
Century Cinemark Theater
Lessons Learned: Areas of improvement
– First Responder Relief
• Days following attack
– Victim Information
• Issues with accurate and timely information for
families
Injury Patterns and
Treatment
C.A.B.C.
• Active shooter / Mass violence
– Different mindset
• Catastrophic hemorrhage
• Airway
• Breathing
• Circulation
Causes of Death
#1 – Hemorrhage
#2 – Tension
Pneumothorax
#3 – Airway
Obstruction
Injury Patterns
• Hemorrhage
– #1 preventable cause of death on the
battlefield
• 66% of preventable deaths!!!
– Various Control Methods
•
•
•
•
Direct Pressure
Pressure dressings
Hemostatic dressings
Tourniquets
Injury Patterns
Clinical presentations of acute hemorrhage:
Class % Blood
Loss
Clinical Signs
I
Up to 750 ml Slight increase in HR; no change in BP
(15%)
or respirations
II
750-1500 ml Increased HR and respirations;
(15-30%)
increased diastolic BP; anxiety, fright or
hostility
III
1500-2000 Increased HR and respirations; fall in
ml (30-40%) systolic BP; significant AMS
IV
>2000
(>40%)
Severe tachycardia; severe lowering of
BP; cold, pale skin; severe AMS
Hemorrhage Control
• Tourniquets
– Safe and effective
• No longer taboo!
– 10+ years of
proven battlefield
use
– Police officers
• Must carry…
– Medics
• Should carry…
Hemorrhage Control
• Tourniquets
– For life threatening
hemorrhage
– First line for life
threatening arterial
bleed
– Not just for active
shooter
– Can remain in place
up to 8 hours
Hemorrhage Control
• Hemostatic Agents
– Impregnated gauze
– Packed into wound
– Used for area
where tourniquets
cannot reach
– Used for less
serious/stepdown
care
• "Stop the Bleed" is a nationwide
campaign to empower individuals to act
quickly and save lives.”
• Public access bleeding control kit
• Emerging concept
Science of Coagulopathy
• Stopped the bleeding… More fluid?
– “Replace what the patient has lost”
• If blood has been lost, give blood (hemorrhage)
• If crystalloid has been lost, give crystalloid
(dehydration)
– But what about my two large bore IV’s?!
• Not so fast…
“Prehospital Intravenous Fluid Administration is
Associated with Higher Mortality in Trauma Patients: A
National Trauma Data Bank Analysis”
Science of Coagulopathy
Is Too Much Fluid Bad???
Two large bore IV’s
infusing WO
Reverses
Vasoconstriction
Dislodges
Clots
Hypothermia
Coagulopathy
Hemodilution
Reduced O2
Delivery
MORE
BLEEDING!!!
Acidosis
Science of Coagulopathy
• Bottom line…
– IV fluids
• Penetrating trauma
– Little to no benefit
– Can cause increased mortality
• Blunt trauma
– Neither good nor bad
• So what do we do?
– Judicious use of fluids to maintain good MAP
pressure
MAP Pressure
2 x Diastolic + Systolic / 3
Given: BP 120/80
Given: BP 90/60
(2 x 80) + 120 = 280
(2 x 60) + 90 = 210
280 / 3 = 93.3
MAP of 93.3
210 / 3 = 70
Map of 70
A MAP of 65 is needed to maintain perfusion to vital
organs… Brain, heart, lungs, kidneys…
Tension Pneumothorax
• What is it?
• When do we
treat it?
• Sometimes
misdiagnosed
• 33% of
battlefield
deaths.
Tension Pneumothorax
• 3” needle
minimum is
new standard
• 2” needle
shown to be
ineffective
Tension Pneumothorax
• Insertion site
– Midclavicular
• 2nd/3rd
intercostal space
– Midaxillary
• 5th/6th intercostal
space
– Which is better?
Airway Obstruction
• 6% of preventable deaths
• Think simple first!
– Especially when you have multiple victims
• Nasal Airway
• Oral Airway
• Recovery position
Recovery Position
Hypothermia
• Is the enemy in the hypovolemic trauma
patient
• Blood is the body’s heat transport system
• Patients can quickly become hypothermic
– Profound effects on clotting
• Room temperature IV fluids exacerbate
• Keep patients warm!
Blast Injuries
Blast Injuries
• Blast Lung
– Most common fatal injury
– Can happen as late as 48 hours after
– Clinical triad
• Apnea
• Bradycardia
• Hypotension
Blast Injury
• Ear Injury
– Frequently overlooked, but not usually fatal
• Abdominal injury
– Gas filled organ
– Susceptible to pressure wave
– Suspect in patients with
• Abdominal pain/GI pain
• Testicular pain
• Hypotension
Blast Injury
• Brain Injury
– TBI
• Abrupt changes due to trauma
• Can affect personality
– One minute normal, next minute not
•
•
•
•
Brain heals differently
No two are alike
Individual may not be aware they have TBI
Can be immediate onset or delayed weeks
Traumatic Brain Injury
• Mild
– <30 minutes loss of consciousness, confusion, or
disorientation
– Profound future effects on mood, emotion, attention
span
– Even though mild, can still be devastating
• Severe
–
–
–
–
>30 minutes of the loss of consciousness
Memory loss
Penetrating skull injury
Impaired physical abilities
Active Shooter Training
ALERRT /Rescue Task Force
ALERRT
• Advanced Law Enforcement Rapid
Response
– Why?
• In response to active shooter incidents
• Developed in 2002
– What
• First arriving officer to engage shooter even if
alone.
• Bypass victims to engage shooter
ALERRT
• What does this mean for you?
– Victims may be police and bystanders
– Officers are your first line of treatment
once threat is neutralized
• Tourniquets
– What is your plan of action when the
officers go racing in to confront the
threat?
ALERRT Conference
• Active shooter conference
• Brings together police and EMS
– Rescue task force and police training
Rescue Task Force
Teams deployed to provide point of
wounding care to victims where there is an
on-going ballistic or explosive threat
Rescue Task Force
• Change from the norm of “EMS is staging till
scene secure”
– EMS entering warm zone with armed escort
• Cleared but not secure area
– Treatment of victims
• Basic, rapid care!
– Hemorrhage control (Tourniquets, hemostatic)
– Not the time for ALS care
– Evacuation of victims
• Logistically and physically exhausting
• Time consuming
Rescue Task Force
• Assigned in groups
– 2 (treatment)
– 4 (movement)
• Casualty collection
point
• Armed protection
– 2 police
• Warm Zone
Rescue Task Force
• Typical Gear
– Tourniquets
– Pressure Dressings
– Chest Seals
– Chest Darts
– Ballistic protection
• Level IIIa vest
• Helmet
Rescue Task Force
• DHS guidelines
for active shooter
events
– Full Document
• RTF
Demonstration
https://youtu.be/_dj
FzEjZuh8
Rescue Task Force
• Fire, EMS, and LE MUST train together!!
– Develop local protocols
– Utilize unified command
– Incorporate TECC
– Provide appropriate protective gear
– Consider secondary devices/IED
– Common terminology
– Train, train, train
TCCC vs. TECC
• TCCC
– Tactical Casualty Combat Care
• Developed for military
• TECC
– Tactical Emergency Casualty Care
• Civilian adaptation of TCCC
• Phases of care
• Utilized by rescue task force
and TEMS
Tactical Emergency Casualty Care
• Direct Threat Care
– Care during active fire fight
• Usually performed by officer or TEMS member
– Basic emergent care! I.E. Tourniquets!
• Indirect threat care
– No longer a threat to the casualty
• Still basic care but more time to assess
• Evacuation care
– Care phase when victim is being removed
from the building
TEMS vs. RTF
TEMS
– Tactical Emergency
Medical Support
– Works directly with
SWAT
– In the hot zone
– Primary task is SWAT
members health
– Can become RTF
once threat is
mitigated
– Trained in SWAT
tactics and
nomenclature
RTF
– Works with police
• Unified Command
– Operates in the warm
zone
– Primary task is civilian
casualties
• Victim removal
Everyday Body Armor
• Local decision
• Cost factor
• Does your
response area
dictate the need
• Stab vs. Ballistic
protection.
K9 Care
Treatment of K9’s
• Specialized Dogs
– Drug sniffing
– Bomb sniffing
– Sight Seeing
– PTSD
– Seizure
– Therapy
– Search and Rescue
Dogs, can we treat them?
• Yes… To a certain extent…
Humane Care for Animals Act
Sec. 16.5. Emergency care to an animal; immunity from civil
liability. Any person, including without limitation any person
licensed under the Veterinary Medicine and Surgery Practice
Act of 2004 or licensed as a veterinarian in any other state or
territory of the United States, who in good faith provides
emergency care or treatment without fee to an injured animal
or an animal separated from its owner due to an emergency
or a disaster is not liable for civil damages as a result of his
or her acts or omissions in providing or arranging further care
or treatment, except for willful or wanton misconduct.
Dog’s, what kind of treatment?
• Keep it basic and non-invasive!
– Bandaging
– Basic oxygenation
– Irrigation
– CPR
• Do not perform advanced skills
– IV
– Medications
Animal Care
• Government Working Dogs
– Consider an agreement
– Government asset/property
• Pets
– No contracts
– Private Property
• Bottom line, if you don’t feel comfortable caring for
animal, there is no legal recourse for not providing care.
• Post traumatic Stress Disorder
– Common in EMS
– Can occurs months after
– Doesn’t have to be related to one large
incident
– Can be due to years of critical stress
– MUST have proper structure, support, and
guidance to know when, how, and where to
seek help
PTSD
PTSD
PTSD
PTSD – How one FF/Paramedic
is recovering…
JEMS Article Link – PTSD
Scenario 1
You are dispatched for the active shooter at
a local office building. Three arriving officers
on scene report the threat is down and there
are a total of 7 victims in the building. As
you gather equipment to enter for treatment,
what do you want to consider bringing?
What other resources will you need? How
will you coordinate and communicate with
officers on scene?
Scenario 1
• Dispatcher Considerations
– How many calls can you call center handle at
one time?
– What happens when calls overload the
system?
• Put them on hold automatically?
• Will them simply get a busy signal?
– How will an active shooter situation affect
your dispatch centers resources?
Scenario 1
• On scene you have 2 greens with minor
abrasions.
• 2 victims are conscious and have GSW to the
arms with copious dark red hemorrhaging
• 2 victims have GSW to the legs are
responsive to pain, pale, with copious bright
red bleeding
• 1 victim is unresponsive with a GSW to the
chest breathing 4 times per minute
Scenario 1
• Which patients are your priorities?
• What are your best treatment options for
each?
• Are there any resources immediately
available to help treat and move patients?
• How will you evacuate your patients?
START Triage
Scenario 2
• You are dispatched to the report of an
active shooter at a local mall. There are
reports of multiple victims in multiple
locations throughout the mall. As you
arrive on scene officers have already
made entry and killed the shooter. As you
pull up you find 18 victims outside. Some
walking around, some sitting, and some
lying down in various areas of the parking
lot yelling at you for help….
Scenario 2
• What is your next action?
– Do you take medical command/triage?
– Or do you begin treatment/transport?
• What are your treatment priorities in this
situation?
• What resources in your response area are
en route? And what others will you need to
call?
Scenario 2
As you begin operations outside, officers inside
the building state there are 20 GSW victims
including young children throughout the mall.
• What is your next course of action?
• Can you communicate with police in your
area?
• Do your officers have the ability to render aid
until more help arrives?
Scenario 2
• How will you move all of these victims?
• Do you now have two separate areas of
treatment and triage?
Skills of the Month
• BLS
– Review system specific procedure for
tourniquet application.
Skill of the Month - ALS
• EZ-IO
– 15g needle
• LD 45mm
• AD 25mm
• PD 15mm
• Utilize for
– Arrest
– Impeding arrest
– System specific
EZ-IO
• Site:
– Humeral Head (Preferred)
• LD needle
– Preferred needle for humeral head!
• Greater flow rates (5L per hour)
• Right into subclavian
– Faster into central circulation
– Proximal Tibia
• Needle choice is patient dependent
• Slower flow rate (1L per hour)
• Often selected due to provider familiarity
EZ-IO
• Always give a rapid flush when
establishing access!
– No flush = No flow
• Always flow fluids under pressure!
– ~300mmHg
– If pressure isn’t maintained there is a risk of
flow stoppage.
Medication of the Month
• Normal Saline
– 0.9%
• Isotonic
• pH of 4.5 to 7.0
– Indications
•
•
•
•
Vascular access
Fluid replacement
Irrigation
Stable croup
Rhythm of the Month
• Asystole
– Without systole
– Determine and treat underlying causes
- Hypovolemia
- Hypoxia
- Hypo/
Hyperkalemia
- Hypoglycemia
- Hypothermia
- Tamponade
- Tension
pneumothorax
- Thrombosis
- Toxins
Asystole
SOP!