Are TEMS or TCCC the right answer?
Maximizing Life-Saving in Active Shootings, Part 2
By: George Williams
In Part One of this article, changing the focus from a police response to a public safety mindset in an Active Shooter event was introduced. In Part Two, we will cover the priorities in the response and whether TEMS or TCCC are the right answer.
Every Active Shooter incident has two fundamental processes, each occurring simultaneously and each time-competitive: 1) the suspect is creating more and more wounded every second he is free to do so, and 2) those wounded are potentially bleeding out. For many, a delay of minutes in getting treatment will be the difference between surviving or not. It is vital to recognize that once the shooting has stopped, the life-threatening emergency continues. Time is of the essence; the clock is running on those injured requiring immediate professional medical care to survive.
The City of Hillsboro, Ore. Police and Fire Services recognized the need to integrate the Mass Casualty Incident (MCI) protocol into the police response to prevent delays in the rescue and treatment of the wounded. Fire’s MCI protocol is a proven method of triaging (categorizing the criticality of the individual’s wounds and conditions), stabilizing, and transporting the wounded to advanced life support facilities.
It is mathematical: the earlier firefighter-medics can be safely inserted into the scene, the more lives will be saved. There are near-simultaneous co-priorities of, first, locating and interrupting the suspect to prevent further wounding of innocents, and, second, the rapid establishment of a secure Casualty Collection Point (CCP) within the location where fire can institute their MCI protocol. Here are the main tactical and procedural components of the Hillsboro model.
PRIORITY ONE: Locate the suspect and interdict the wounding cycle
Historically, the police have little influence in physically stopping the suspect’s murder spree. In only 25 out of more than 335 incidents since 1966 have on-duty officers actually interrupted suspects in an Active Shooter incident.
The early entry by police is vital for a number of reasons: There is a chance the suspect may still be actively shooting and wounding people. There is a greater likelihood of the suspect committing suicide after realizing officers are nearing. Officers gain a secure initial foothold into the structure and then rapidly clear the structure of threat.
In this model, officers are trained to enter the structure as pragmatically as possible. They are given the discretion of solo or two-officer buddy team entry. History has proven multiple officer formations to be too late, too slow, and too unwieldy to be practical in an Active Shooter incident. Ideally, officers enter through different ingress points permitting a more complete domination of the structure through multiple avenues of approach.
Indicators of Threat
First-arriving officers initially move toward any indicators of threat such as gunfire, information through 9-1-1 dispatch, individuals pointing, people frantically fleeing from an area of perceived danger, etc. Bypassing doors, the officers move at a rate they are comfortable with given the situation. Sometimes they might run, then as they near the suspect’s suspected location, movement may become more cautious.
As additional officers arrive, multiple officers tend to respond together, traveling in a loose overwatch with the point officers concerned with specific uncleared corners, while the trailing officers tend to distant cover. As contact with the suspect becomes probable, they may slow to a quick-bounding overwatch, moving from corner to corner, or the point officer may continue until there is a clear firing angle on the suspect.
No Indicators of Threat
If there are no indicators, there is a bifurcation of priorities: Officers move quickly through the structure, taking control of key terrain features such as hallways, stairwell exits, and elevators as others establish and secure a CCP. When a trail of wounded is present, officers use that indicator to locate and clear the area of threat. With a few officers securing the key areas with their rifles, other officers locate the suspect while still others begin transferring the wounded to the CCP.
The term “locate” the suspect is deliberately used rather than “search for.” From Day One of the academy, officers have been trained that a search is a comprehensive, thorough process, whether it is a search of a prisoner or a search of a building. In an Active Shooter incident, time is of the essence. It is vital to quickly find the suspect and confirm he is dead, fled, or to take him into custody.
PRIORITY ONE-A: Designate and Secure the CCP Early
Fire’s MCI protocol is a proven method of providing timely emergency medical care to large numbers of injured. The Golden Hour concept dictates that the severely injured will survive only if they are treated in an advanced life-support facility within 60 minutes of the onset of injury. To meet this 60-minute deadline, firefighter-medics must quickly access the wounded. Minutes do count.
The MCI protocol is conducted in a Casualty Collection Point (CCP) established and reasonably secured within minutes of the initial police entry. This is similar in concept to a HazMat “warm zone”—personnel are able to operate within this area with defined precautions. Fire describes this as “calculating risk.” Fire will not inject themselves into a full risk situation outside of their training. They will proceed if that risk percentage is lowered, making the calculated risk justifiable.
It is up to the police to identify the location of the CCP within the facility. It is secured by no more than four officers, and often two. The concept of establishing a CCP while combat operations are ongoing is not new. The goal is for fire personnel to step into the CCP within 10-12 minutes of the first officer’s entry.
Why Not TCCC or TEMS?
Some in law enforcement have recognized the need for early EMS intervention. Solutions have centered around Tactical Combat Casualty Care (TCCC) and Tactical Emergency Medical Support (TEMS). Unfortunately, neither of these solutions is able to manage a Mass Casualty Incident.
TCCC, or “Self-Aid, Buddy-Aid,” was developed by the military to offset preventable deaths on the battlefield. Personnel are trained to quickly respond while under fire to life-threatening traumatic injuries. In the mass casualty event, officers apply Buddy-Aid procedures to prevent severe blood loss and establish airways.
TCCC is a stop-gap measure designed to limit additional casualties by immediately addressing the most common life-threatening injuries without sustaining further wounds either to the victim or rescuers. Once the injured can be extracted safely, they are transported immediately to the CCP in a mass casualty incident, or directly to a treatment facility if an individual casualty.
In the mass casualty incident, TCCC alone is insufficient. For example, in the Active Incident involving Rep. Gabrielle Giffords in Tucson, Ariz., Pima County Sheriff’s deputies are rightly credited with saving the lives of victims by applying their TCCC training. Rather than validating the TCCC concept, this incident actually confirms the value of a CCP. The shooting took place on the sidewalk outside of a Safeway grocery store. There were five dead and 14 wounded all in one specific location with access for fire and ambulances.
Additionally, a married doctor and nurse immediately set up triage. Rep. Giffords was transported and on the operating table within 53 minutes of being shot. Her neurosurgeon credited her survival to her rapid transport. Establishing the CCP, rapidly triaging and stabilizing the patients, and the efficient transport of the wounded saved lives.
TEMS is an advanced approach to caring for the wounded and injured while under fire. A SWAT-trained physician or paramedic embedded within a team is able to move and operate in the hot zone under the direction of the team leader. The TEMS concept provides advanced life support capabilities to a wounded individual (officer, bystander, victim or suspect) when it is not possible to extract him/her from the crime scene due to the danger presented by suspects.
A TEMS qualified operator is a physician or a certified paramedic as well as SWAT certified. Equipping the TEMS operator is expensive given both the medical and the SWAT protective equipment. In addition to the basic SWAT certification, there are ongoing physical fitness standards and training requirements to maintain SWAT qualification.
There are fundamental problems with TEMS during an Active Shooter incident. There is a lack of TEMS qualified operators in any single region. TEMS operates in pods of four armed officers, escorting the TEMS operator into the warm crime scene to begin treatment of the wounded. If 10 TEMS operators could be rapidly located and transported to the scene, 40 officers would be required for security—this requires time in assembling each team.
TEMS is intended to provide care under fire. By the time the TEMS operator enters the location, the suspect will have long been located or secured. The operator’s medical skills will be better employed in the stabilization of the wounded at the CCP rather than being fed piecemeal into the location. TEMS cannot efficiently process large numbers of wounded.
Within the Hillsboro CMCI model, for the cost of one supervisor, two officers for CCP security, and two or more officers to provide convoy security for fire apparatus, law enforcement receives the full resources of the local fire department plus allied fire agencies as they arrive. The police are able to perform rescue operations as soon as the CCP is secure, rather than calling in frustration for medics to respond.
The CCP also functions as a Forward Operating Base for police supervisors to coordinate internal operations distinct from the CP, such as forming ad hoc search or rescue teams, identifying a problem where more or fewer officers are needed, and other immediate supervisory needs.
Establish a “Joint” Command Post Early
Bringing two public safety disciplines together requires a level of flexibility. For the police a “unified” command means that different entities are working together in a single location. For the fire service, a Unified Command is a formal structure within the Incident Command System for the implementation of National Information Management System (NIMS) protocols. A Unified Command Post generally requires one or more hours to set up and is intended to manage a large event over a period of days or weeks.
A “Joint Command Post” (JCP) permits police and fire commands to better obtain and coordinate resources. A JCP assists commanders in assessing the incident as well as helping to prevent both services from working at cross purposes.
In the Hillsboro model, a police lieutenant and a fire battalion chief meet at the Fire Staging location a short distance from the incident. Dispatch sets up a radio network patch to permit both services to monitor police and fire broadcast. Once the CCP has been set up and declared reasonably secure, the JCP gives permission for fire personnel to enter. The JCP coordinates EMS ambulance arrival and departure, and assignment of patient destination on a separate frequency from the patched channel.
Most Efficient Life-Saving Method
The Hillsboro model response to a criminal event where numerous casualties have resulted is practical and meets the fundamental goal of saving the lives of those who can be saved. It represents an evolving understanding of these events—an Active Shooter is not solely a police event.
The near-simultaneous co-priorities of locating the shooter and the early establishment of the CCP addresses both the need to stop the wounding cycle as well as the need for the wounded to have immediate access to medical attention. To stop the suspect, officers are permitted to make solo or multiple-officer entry—or to delay entry—based on their on-the-spot assessment of the situation. Officers are tasked with locating the suspect as rapidly as possible. A formal search will be conducted by officers and SWAT following the evacuation of the wounded.
As soon as there are sufficient resources seeking the suspect’s location, a CCP is established by officers. Any officer may set up the CCP, and officers are assigned to act as security. Once the secured CCP is established, firefighters in their vehicles and equipment are released to move with their armed police escorts to the CCP where the officers will act as additional security within the CCP or at the exterior where the ambulances are loading patients.
Stopping a suspect from shooting innocent people and to care for the wounded: The specialties of both the police and fire are required to meet these needs. We will never be able to prevent these events from occurring, but we can make a difference in how many victims die as a result.
George T. Williams is the Director of Training for Cutting Edge Training in Bellingham, Wash. He has been a Police Training Specialist for more than three decades, as well as an expert witness in federal and state courts nationwide and a widely published author for more than two decades. Mr. Williams develops and presents revolutionary concepts within integrated force training solutions through a problem-solving format, functionalizing police skills and tactical training. He may be contacted at firstname.lastname@example.org.
Don't Throw TEMS or TCCC out with the Bathwater!
By Sgt. W. Blake Strickland
My name is W. Blake Strickland and I currently serve as a Patrol Sergeant with the University of Alabama-Birmingham (UAB) Police Department and am a current NREMT-Intermediate. I have served in the fire/ EMS/ Law Enforcement field since 1988. In 1999, I was serving as a supervisor for the Homewood (AL) Police Department Tactical Unit and had the privilege of starting the first tactical medical support group for our team. I partnered with Dr. Guiermo Pierluisi with the UAB Hospital-Emergency Room and expanded our medical support beyond our tactical unit to area agencies, to include Alabama State Troopers, FBI, US Secret Service, ATF, DEA and numerous local/ county agencies. Our group was recognized as the first tactical medical support group utilized by the US Secret Service in the United States. Over several years, this group expanded into a training group and formed the Alabama Tactical & Terrorism Operational Medical Support (ATTOMS) Group.
In response to this article, I first want to state that I fully support Sgt. Allen (Hillsboro PD), Jeff Gurske and Abe Madrigal (Hillsboro FD) creating a program that better integrates police/ fire/ EMS into the active shooter/ mass casualty incidents. In everything that I’ve read regarding their city’s integrated protocol, they definitely are on the right track. However, I disagree with the author of this article, George Williams, in his assertion that TCCC and TEMS have no place in this type of environment. Obviously, Mr. Williams is a highly qualified individual, but I believe that his point of view is not one that is easily shared in different areas of the country, especially, the southeast, where large police and fire departments are not the “norm”. In the State of Alabama, the average size police department is less than forty (40) officers.
It is definitely the first priority to stop the active shooting/ shooter and I would add it’s also part of that priority to determine if the initial event (shooting) has ended. The quicker that law enforcement can determine the scene is no longer posing an immediate threat, the more quickly resources can be moved into the area. In order for fire/ EMS to bring their expertise and resources into the situation, we have utilized TEMS-trained personnel in several ways. Firstly, to train law enforcement to initiate triage and make sound decisions on moving viable, sustainable patients to a semi-secure location, or casualty collection point (CCP) within the structure or just outside. As time is critical in the care and transportation of these patients, moving victims that are deceased or not medically feasible to make the trip to a medical care facility would be an unfortunate waste of time and resources. The officers are trained to use basic “self-aid/ buddy-aid” techniques to quickly determine if a victim is ambulatory and able to self-extract to the established treatment area or provide immediate life-saving bleeding or airway management. As an aside, Mr. Williams’ article spoke of TEMS operating in pods of four (4) armed officers who escort one (1) TEMS personnel into a scene. As most of the TEMS operators that I know or work with are cross-trained and armed, this type of escort is not needed.
Secondly, TEMS-trained personnel train fire/ EMS personnel in the best way to integrate in these types of incidents with law enforcement. As the statistics have shown, fire/ EMS will generally arrive after the shooter (s) has been neutralized. The moving of their personnel into the scene, especially the area designated for injured, has become less of an issue with the traditional “staging” protocol. As fire/ EMS have trained for decades in “mass casualty” drills, the TEMS operator is very qualified in efficiently processing large numbers of wounded, which is also in conflict with Mr. Williams’ article.
Lastly, it is with Mr. Williams’ claims that TEMS aren’t feasible due to the expense in training and equipping them, I believe that I take the greatest offense. Since the vast majority of TEMS operators in our area are primarily fire/ EMS personnel, their agencies provide them with the medical supplies/ equipment they need for call-outs. We take the old adage of “improvise, adapt and overcome” to heart! Additionally, as they may be actually on duty when one of the events occurs, they are allowed to “take point” and get needed personnel and equipment into the area based on their training with law enforcement.
I appreciate Mr. Williams’ service to our profession and for the Hillsboro Police and Fire Departments taking the lead in bringing “common sense” back to these incidents. I hope that both groups can realize that we don’t need to exclude any public safety personnel from these horrific incidents, but through training can utilize all the talent, resources and abilities to provide to best possible care to the victims!
Thank you for your time and patience in letting me present another point of view.
Submitted Nov 3 at 11:21 AM