Why active shooters and MCIs are different animals
When teaming with police, fire and EMS need different tactics and tools for both scenarios
By Dennis Ortiz
I was recently observing an active-shooter drill where a fire and law Rescue Task Force was preparing to move downrange. One of the paramedics embedded in the RTF touched the shoulder of the RTF force protection point man. As soon as the deputy started moving forward, law enforcement cancelled the drill.
On another drill, an RTF pod was nearing the warm zone entrance when an embedded fire medic yelled out, "If you can hear my voice, come to me."
We learn from our mistakes, and ones such as these should be expected as putting firefighters in the warm zone is explored and tested.
We are melding two cultures that view patients in different ways. Police approach victims as "who are you," while the fire-EMS approach is "how are you."
With many departments forming the capability to operate in warm zones, it is a good time to reflect on methods that have emerged and discuss how well they are grounded.
Task force anatomy
An RTF has three defined mission objectives: casualty care, patient viability marking and patient movement. These objectives are divided among the medical component — tasked with casualty care and viability marking — and the extraction component that facilitates the rapid extraction of viable patients.
The medical component is embedded with a law force protection group and operates primarily in the warm zone. The extraction component usually has a lighter force protection and briefly enters the warm zone to reach and rapidly extract viable patients.
So when envisioning an RTF, it is not a single, slow-moving pod of firefighters surrounded by tactical operators treating and moving patients one-by-one. Instead it is a protected medical team always moving forward leaving behind a breadcrumb trail of hastily treated casualties for the extraction teams that follow.
Unlike traditional triage color markings in a mass-casualty incident, patient markings in an active-shooter event serves a different purpose. In an MCI, the objective of triage is to quickly obtain a patient count by acuity color so needed resource can be allocated.
Active shooter incidents are not MCIs from an RTF perspective, so triage serves no useful purpose. Instead the purpose of marking a patient in the warm-zone is solely to distinguish the living from the dead so extraction teams can quickly identify those who need to be moved to the casualty collection point.
Generally, black and white ribbons are optimal for marking non-viable patients. Yet to be resolved is the optimal color to represent viable and if more than one viable category and color should be used.
One color or two?
For viable patients there are two schools of thought: Use a single color to indicate viable patients or use two to indicate viable-critical and viable-non-critical.
Tactically and practically two colors are unnecessary. All patients in a warm zone are under threat to life. If they are unable to limp or crawl from that threat, they have severe injuries and should be extracted as they are encountered.
Setting some sort of priority system based on injury severity adds an unnecessary level of complexity in an already complex event. To responsibly determine the severity of ballistic injuries a primary survey must be conducted. There is no time for that.
This makes it a subjective decision. This is no place for that.
It also implies the extraction team would potentially bypass non-critical patients in search of critical patients. This is especially true if red is the critical color and yellow is the non-critical color as the firefighter mind-set is to bypass yellows in search of reds.
And if they were to not bypass the non-critical to reach a visible critical a little further up the hallway, then what purpose did the non-critical category serve? When a viable patient is encountered, extract them.
If two patients are side-by-side and one appears to gain the most benefit by immediate extraction, then extract them first. But in that rare instance it will be a call for the extraction team to make. We don't need to throw a ribbon at the decision.
For viable patients who are unable to self-extract, firefighters natural tendency is to mark them with red ribbons or chemlights.
This is a problem for two reasons. The first is a potential interoperability issue between fire and law. Red is a common color used by law enforcement for tactical room clearing and marking procedures. It signifies danger in adherence with the ANSI/NATO Part Z535 Safety Color Coding Standard.
Wrapping a red ribbon on a patient effectively tells a tactical operator to ensure all personnel stay back and avoid that threat. It is imperative that fire departments check with all law agencies in and near their jurisdiction before deciding to use red as a marking color.
Second, austere triage, such as START, is not used in warm-zone operations. Red can be problematic when patients with what appears to be START markings are brought into a cold-zone using true triage color marking. If patients begin to stack up, the triage teams may not be able to discern which patients they have assessed, counted and prioritized.
This problem is compounded further if the RTF is using yellow ribbons to mark non-critical patients.
All said it appears the best viable marking color is blue. It has a neutral ANSI Z535 safety color designation, is readily available, is not used by law enforcement and is not part of the START pallet.
A new concept says that since MCI and active-shooter responses are similar, the tools and techniques should also be similar. This has extended to the idea that the medical load-outs used in active-shooter kits can also be used in an MCI.
In some quarters, this has led to changing the methods used to mark patients in an MCI, including entirely eliminating the marking of the walking wounded during initial triage because ribbon dispensers designed specifically for active shooter don't contain green ribbons.
Such radical evolutions should be considered with extreme caution.
Our decisions should begin with a patient-centric approach to maximize life-saving, not an equipment-centric approach to maximize cost savings. MCI and active-shooter incidents have virtually no similarities.
The RTF medical component that is treating and marking patients is not in an MCI regardless of the scale of the incident. To blend these unique tools will result in degraded mission performance and patient outcome.
The walking wounded
The RTF ribbon color is a minor issue and will work itself out. The concept of bringing a full life-saving intervention load out into an MCI triage environment is simply a bad idea. The equipment will get used and triage will be slowed.
Not having the ability to mark those who can walk is equally problematic.
The theory is that the walking self-identify and there is no need to visually indicate they have been assessed or counted. Nothing could be further from the truth.
It ignores that often those who can walk do so with either a non-ambulatory patient in tow or with injuries to themselves that should render them unable to walk. It is imperative that these "greens" be assessed, marked and counted so a rapid acuity size-up can be obtained and proper medical resources provided.
Equally important is the marking of those who can walk but elect to stay in the casualty area to provide care to other patients. This is an inevitable and good occurrence. But without the ability to mark and count that kneeling Samaritan with a green ribbon, other triage members will waste precious time re-evaluating that patient.
When taking an all-risk approach to defining triage tools, green becomes even more important. Blast environments will generate patients that simply cannot hear and will not obey any verbal commands. These wandering walking must be counted and marked.
The same is true when language barriers exist. Compound these issues with a multi-jurisdictional response with an agency that does use green and interoperability goes out the window.
There is no magic bullet that will serve the needs of MCI and active-shooter incidents. Force-fitting tools to work in both should be avoided if possible.
The new normal
The LAX shooting drove home the message that fire and EMS cannot stand by while patients bleed. Although the TSA agent was not viable, the perception was that we should have been there.
At the national level, law enforcement has realized the obvious — That they are closest to the patients and most logical element to provide immediate care.
Law enforcement agencies across the country are expanding their tactical EMS, or TEMS, guidelines to include civilian casualty care. Tactical emergency casualty care programs have seen a huge uptick over the last three years, enabling frontline tactical operators to have the equipment, skills needed to provide civilian care in both hot and warm zones.
Even patrol officers are expanding their first aid kits to include treatment gloves, multiple tourniquets and combat gauze to manage civilian casualties. Many law enforcement agencies' SOPs for an active shooter now incorporate the establishment of a tactical casualty collection point in the warm-zone to better facilitate victim safety and extraction.
Having our law enforcement counterparts manage warm-zone operations is a good thing and does not make us irrelevant. There is plenty to do in the cold zone and rapid extraction operations would remain in our wheelhouse.
It does make us safer and it makes them safer as well. Our lack of true tactical movement skills (show me the military hand sign for quiet) makes us a liability in the pod. Our glow-in-the-dark camouflage, lack of weapons familiarity and untested hostile-fire experience all contribute to us not being at the level of mission effectiveness we would like to believe.
There is reason to assume that our mission will shift in the future and if that shift does not degrade patient outcome and makes us safer, we should prepare to embrace it. For now our public is best served by having us continue to strive for the best possible RTF plan we can muster.
About the author
Dennis Ortiz is a retired Los Angeles County Fire captain and EMS coordinator with 34 years of experience. He currently owns and operates Disaster Management Systems, a supplier and training operation for MCI tools and tactics.