I worked my hardest to become and maintain National Registry Emergency Medical Technician - Basic (NREMT-B) certification right after I was appointed fire chief. I wanted to demonstrate the same skill set demanded of the members; leading by example is a long-time core personal value.
In the mid-1990s, I found myself impatiently watching the mail for my NREMT-B test results. Finally, the white tyvek envelop showed up. The hard work and effort paid off, the gold threaded shoulder patches would soon be added to all of my uniform shirts.
It seems like only yesterday that I was sitting in the front of the Fire-Rescue Training Center classroom at the Westgate Fire Station. The course instructors, Paramedic/Battalion Chief Larry Williams and his training staff, promised all of the students that if we worked hard and studied the textbook they would help everyone to get through the all-important final national registry examination.
After four weeks of class work, he was true to his word. The entire EMT class became NREMT-Bs. I likely didn't thank the chief and his team enough for their efforts. So, I give public thanks to Chief Williams and staff — better late than never.
"Scene is safe"
Chief Williams and his staff insisted that we be able to perform every required NREMT-B skill flawlessly. Each time a student would be put through a skills simulation, that EMT candidate would verbalize, "body substance isolation techniques in place by all responders."
Next, the class members would take a 360-degree look around the staged emergency medical scene. Perhaps the chief added a downed electrical power line or a crazed bystander wielding a knife for the trainee to contend with and successful resolve.
Once the area was cleared of obvious dangers, the student gave the "scene is safe." It was at this point, our practical skills instructor would respond back that he/she copied that body substance isolation equipment was in place and the emergency incident scene was rendered safe to enter.
This two-step process was drilled into everyone who participated in this emergency medical training program.
The real deal
Move the calendar up about 10 years. I knowingly participated in a major operation that broke the emergency "scene is safe" rule.
In fact, the incident called into question the long-standing wisdom about always making sure that the scene is safe before engaging in delivering patient care. As this event unfolded, it didn't seem like I would be engaging our personnel in this high-risk fashion.
It was Friday, March 11, 2005 just before 9 a.m. I was serving as Atlanta's fire chief. I had just completed a meeting at city hall when Paramedic Engine 1 provided an on-scene report of a man down at Martin Luther King Avenue just before Pryor Street.
Soon after, the fire company officer reported that there was a Fulton County Deputy Sheriff who had been shot and advanced life support protocols were being implemented. Being in close proximity to this alarm, I responded to see how I could assist.
We quickly learned that the deputy was fatally shot, but didn't know this officer was part of a much larger active-shooter incident.
The on-scene sheriff deputies were asking for help inside the courthouse for persons who had been shot in one of the courtrooms. I immediately declared a major medical event and asked for a mass causality response with four ALS ambulances.
Next, it was time to set up command on the trunk lid of my chief's car. The initial incident action plan was simple: ensure there were enough emergency medical resources to handle the victims who would soon be removed from the courthouse. We notified local hospitals to request the emergency departments prepare to manage multiple gunshot victims.
To complete the initial IAP, there were other issues that would have to be resolved. In particular, this large incident site would require tracking on-location companies and their assignments to account for everyone at the event.
This incident would also require command to establish a public information officer to keep the mayor's office informed of the fire rescue department's operations and to help with the media as requested. And it would be necessary to stage incoming units in an area that was safe for the evolving law enforcement operation and not blocking ambulance access or egress.
All great plans
Firefighter/paramedics and the necessary ALS equipment were positioned in front of the courthouse and in close proximity to the command post. My plan was that the serious to critically injured would be removed from the building and the pre-hospital care teams would be assigned a patient, an ambulance and on their way to the hospital as quick as possible.
The planned process was simply not happening. No patients were being removed from inside this very large judicial facility.
About then Dr. James Augustine, our medical director and assistant fire chief, arrived. I was quite pleased to have him at the command post asked him to validate the IAP. Dr. Augustine concurred and we intended to move forward with the plan.
A Fulton County deputy sheriff was assigned as liaison with the fire command post. The details that the deputy provided were not very promising.
The belief was that the sergeant who was murdered on the street next to the courthouse was in pursuit of a criminal who had escaped while being transported from the jail to the courtroom for this day's proceedings in a lengthy criminal case.
When asked if the alleged perpetrator was gone from the scene, the answer was a chilling "we are unsure." We asked more size-up seeking questions this officer.
- Was the shooter operating alone?
- Were long weapons or automatic weapons involved in the shootings?
- Was there anyone else shooting inside of the courthouse?
- Has the shooter(s) inside the courthouse been neutralized?
- What are the locations of the people shot inside the building?
His answers to all of our questions: "We are unsure." The officer did say that a SWAT unit was being assembled in front of the building.
The potential life loss caused by the delay in reaching and removing the injured was a real possibility. Dr. Augustine strongly suggested that he should travel with SWAT into the hot zone to triage, treat and remove the shooting victims.
I reluctantly agreed to his heroic request. Dr. Augustine was assigned several firefighter/paramedics who volunteered to go into the hazard zone.
In minutes police made entry; immediately trailing SWAT was Dr. Augustine and two fire fighter/paramedics with a small amount of medical equipment. As each floor of the courthouse was systematically searched and swept for victims, the doctor gave a detail radio situation report to command. An operational line drawing of the building was updated at the same time.
The news from inside the building was not very good. There were two fatalities — a judge and a court reporter. Another deputy was in critical condition from a reported gunshot wound — it turned out the officer was beaten severely, not shot.
The deputy was treated and rapidly transported to a receiving facility where she survived. Another patient suffered severe chest pains. He was provided with pre-hospital advanced cardiac care treatment and transportation.
Finally, there were several other minor injuries. Those simple bruises and cuts occurred in people who were running to avoid being shot.
One major step that was missing, and I take full responsibility, was providing post critical incident stress debriefing of the members on location with emphasis on those who entered the hazard zone.
Questioning long-held wisdom
I had serious second thoughts about sending that team into a highly hostile and volatile dynamic situation. The only protection that my team was afforded was the coverage that SWAT members could provide.
As it turned out, quadruple murderer Brian Nichols had escaped the scene and was a lone gunman. Of course, this was unknown at the time of the entry into the hot zone.
After years of training pre-hospital care providers to ensure that the scene is safe, that wisdom is now being questioned.
The U.S. Fire Administration reports that the average active shooter event end within a few minutes. The Fulton County courthouse shooting in 2005 followed the average.
Generally a shooting victim's injuries are critical to life threading. The active shooter will likely use a high-powered, large-caliber automatic or semi-automatic weapon, causing critical penetrating wounds and hemorrhage. Evidence-based emergency medicine mandates immediate pre-hospital interventions.
The bleeding must be controlled or stopped, if possible. The patient's airway has to be opened and maintained as well. Fluid replacement may be needed quickly to restore perfusion. Finally, rapid transportation to a receiving hospital — preferably a shock-trauma center — will be the required. Once there, surgery is likely.
How to save lives
Armed with this information, it is clear that if there is any chance of saving human lives at an active-shooter event there are three mission-crucial steps that we have to provide.
- Hemorrhage must be stopped.
- Rapid removal to the treatment area for immediate pre-hospital care.
- Expeditious transportation to a trauma-care facility.
If on-scene emergency medical care is withheld until the scene is safe, victim outcomes are clearly compromised. This emerging situation raises many questions, challenges and of course, opportunities.
The questions that must be answered are fairly simple to formulate, but very difficult to answer. Here are 10 of those hard questions.
- Do we continue to use the mandate of scene safe or don't enter the area?
- Is there a place for pre-hospital care givers to enter an active-shooter hazard zone?
- Do we travel with SWAT during the entry and search for victims?
- If EMS goes in to the hazard zone, what additional training is the need?
- What personal protective equipment will be needed (bullet-proof vests, ballistics helmets, weapons, etc)?
- What certifications and authorities (limited police powers) are necessary to perform this service?
- What are the re-certification cycles for training?
- What is the replacement cycle for the protective equipment?
- What type of pay increase is appropriate?
- Is participation in this type of program voluntary or mandatory?
Like military field medics
A program called Counter Narcotics and Terrorism Operational Medical Support, tactical medic for short, prepares paramedics to travel with SWAT units to provide care for injured public safety members. The framework was similar to a military field medic.
Perhaps the tactical medic program could become the curriculum for the active shooter hazard zone entry process. Of course, the mission will be expanded to care for public safety officers and civilian victims.
Looking at the devastating active-shooter events in places like West Webster, N.Y. and Newtown, Conn., we need a different approach. If paramedics have been making tactical medic entries for years to protect police officers, we need to seriously consider expanding this program to add the growing numbers of victims of active-shooter violence.
Getting a verbal "scene is safe" before proceeding is still critical on most calls. But changing times and tactics make us rethink the absolute nature of that rule.