The tragic shooting events such as those we saw at Sandy Hook Elementary School in Newtown, Conn., pose the highest level of preparedness needs for EMS first responders. One of the obvious preparedness elements of the recent events: it can happen anywhere.
What are the priorities for first arriving rescuers? These scenes call for the closest cooperation with law enforcement personnel, the anticipation of secondary issues, and the utilization of medical care priorities that are practiced every day.
Successful and safe emergency scene management in these incidents begins with the everyday use of the Incident Management System.
This structured system, when utilized every day, allows for a prioritized approach to the safe mitigation of emergencies of all types, and effective use of emergency personnel and resources.
At a shooting incident with multiple victims, the operation must be carefully integrated with law enforcement, and any other needed resources (like school officials). All will need to cooperate to accomplish a predictable set of priorities:
The original perpetrator(s) must be disarmed and placed in the hands of law enforcement
Secondary devices must be identified and the impact of them minimized (secondary devices or incidents have been an element in almost all of the multiple victim incidents in recent years). If devices are in or near the original scene, they represent an ongoing hazard to the rescuers and original set of victims.
Secondary scenes are very common, and EMS officers must be prepared to dispatch additional resources to a secondary scene for other victims or to support law enforcement.
Rapid notification of receiving hospitals
At a time when there is little information or a complete victim count, the closest hospital is likely to be seeing the first victims. Emergency Departments should be notified at the first time it is apparent that a major incident is unfolding.
Victims must be provided rapid triage, lifesaving treatment, and rapid transport from the scene. Especially when the scene cannot be completely secured or when secondary devices are a risk, rapid victim removal must be accomplished.
The first arriving rescuers are likely to be in immediate contact with law enforcement and/or school officials. Balancing the needs for immediate medical care of victims must be the development of the needed Incident Command for EMS, and establishing a triage system appropriate for the incident.
Many EMS systems will make the first ambulance or two at the incident a scene resource, and not a transport vehicle. Therefore, the first arriving ambulance that will be dedicated to transport should be tasked with establishing a transportation area, and setting up the logistics of moving ambulances into and out of the area.
This will be increasingly important as more EMS, fire, law enforcement, and other vehicles arrive at the scene and traffic movement gets much more difficult. The worst of frustrations will occur if victims cannot be cared for in a timely manner because the ambulances cannot move through traffic into or out of the scene.
Another critical element
Victim tracking is another critical element to be addressed by the second arriving EMS crews. When multiple victims are going to be transported there must be a dedicated effort to track the identities. Triage tags with identifying numbers are very helpful. Even a device as simple as a black magic marker writing a patient identifying number on the back of the victims’ hands will allow better tracking, and a uniform way to track all patients from the incident.
As the emergency or victim count gets larger, the system is scaled up in a routine matter. Incident Command must organize needed resources to complete the operation. Command must be prepared to do triage at multiple sites (like the three or four exits from a school, theatre, or mall) and establish multiple transportation areas.
Most of these incidents are too unstable to do extensive medical procedures at the scene, so a large equipment cache is not helpful. Providers must be prepared to receive and move patients quickly, and do any lifesaving procedures enroute to the hospital.
Air ambulances are rarely a transport option in a multiple victim shooting incident, as the scene is not stable enough to safely manage a landing. In a few cases, where trauma centers are some distance away, one or more medical helicopters may stage some distance away from the incident site and provide some needed ALS resources at the scene, or do some carefully selected patient transports as time goes on.
Command must ensure a safe operation is undertaken by rescuers. Anticipate that there will be a concern for secondary devices that may threaten responders or create more victims. Command areas may be established a distance away from the incident site, making radio communications using tactical channels a necessity.
Anticipate the immediate psychological stress on the victims, bystanders, and rescuers. Every emergency responder approaching the scene is going to be concerned that a family member or friend is involved, and this may actually incapacitate some of the rescuers.
Every fire and EMS officer must be prepared to deal with immediate stress issues in their crew members. Some consideration needs to take place to allow rescuers to insure that their family members are OK, so that they can participate fully in the operation without an incapacitating distraction that a family member is among the victims.
Working with law enforcement
Careful coordination of the initial operation with law enforcement personnel is necessary, and dispatching resources may also be terribly stressed. In many communities, one dispatcher may be on duty and have to handle all incident communications and resource coordination for police, EMS and fire. EMS leaders should have necessary phone numbers or radio frequencies already programmed in their phones/radios, so they can do direct communications with needed resources.
These incidents mandate the availability of great mutual aid resources. Mutual aid will be needed to manage the full scope of operations that will occur. The EMS officer should anticipate the need for ambulances:
• At the original scene
• At the collection site(s) where the rest of the students, bystanders, and other near-victims are being directed
• To deal with victims of secondary devices
• To deal with a secondary law enforcement incident site or sites, which has been a consistent element of each of the recent shooting events
• At the initial receiving hospital(s), where some victims may need to be transferred to another hospital
• At the sites where incident debriefing are taking place
• To serve the rest of the involved community, where routine medical emergencies are still occurring
Victim care is managed using triage principles developed by the CDC National Center for Injury Prevention and Control. These triage guidelines are a great resource for training and routine use in all multiple casualty incidents.
The "Recommendations of the National Expert Panel on Field Triage" are available in unlimited quantities to EMS agencies. Victim treatment is initiated based on the patient needs, the availability of advanced life support personnel, the climate, and the availability of transport vehicles.
There are situations where advanced life support personnel may be available from sources other than the EMS organizational responders.
Bystanders at the scene may include some physicians, nurses, paramedics and other trained personnel.
All of these skilled personnel may be able to contribute significantly to patient care, as long as they understand their role as Good Samaritans, do not attempt to take over control from the responsible EMS providers, and can adequately identify themselves (with a license or equivalent) as possessing the degree they report they have.
These are devastating incidents, and the immediate and delayed psychological responses among the original EMS, fire, and law enforcement personnel must be addressed. As soon as the immediate medical work is done, Command must be working to establish appropriate debriefing resources, and notify all personnel of their availability.
In conclusion, shooting incidents with multiple casualties present extreme challenges for EMS incident management.
Good organization using Incident Command and application of safety skills will benefit victims and rescuers. Everyday excellence in operations and working relationships with local law enforcement will result in the best patient care.
Recommendations of the National Expert Panel on Field Triage Morbidity and Mortality Weekly Report January 23, 2009 / Vol. 58 / No. RR-1 www.cdc.gov/mmwr
About the author
James J Augustine, M.D., is medical advisor for Washington Township Fire Department in the Dayton, Ohio, area. He is Director of Clinical Operations at EMP Management in Canton, Ohio, and a clinical associate professor in the Department of Emergency Medicine at Wright State University. He formerly served as Assistant Fire Chief and Medical Director for Washington, DC Fire EMS. He has served 29 years as a firefighter, and was the first Chair of the Ohio EMS Board.
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