It is time we moved forward with training that actually will save lives.
Maximizing Life-Saving in Active Shootings, Part 1
By: George Williams
We have a lot of information about these events, although, unfortunately, statistics cannot predict future events. Problematically, officers historically arrive in time to interrupt the shooting in less than one of every 13 events. From 2008 to 2011, the average spree killing—the rapid mass murder of innocents without hostages—took place in less than three minutes.
Suspects have recently become even quicker with their murders since 2011, typically concluding within two minutes. (The 2012 Aurora movie theater shooting took less than a minute with 70 persons shot.) There are inevitable delays between the initial 9-1-1 call and the first officer to arrive. It is extremely rare for police to interrupt the wounding cycle.
Officers tend to arrive singly at first, often arriving many seconds or even minutes apart. Within 10–15 minutes, police resources begin to pour in as available officers from surrounding agencies respond. Within 30 minutes, officers from surrounding counties begin to arrive. SWAT teams become available within one hour. Literally hundreds of patrol cars clog the arteries leading to the location, freezing traffic for blocks. Separate police and fire Command Posts (CP) are set up. Fire stages some distance away from the scene, awaiting permission to begin its Mass Casualty Incident protocols (MCI).
Inside, the police begin to realize the wounded are untended and bleeding out. As search operations are conducted to ensure the entire structure is clear of threat, some officers now focus on the wounded. Frustrated calls for ambulances are radioed. Officers eventually begin dragging the wounded out of the structure, sometimes as far as one-quarter mile to anxiously awaiting firefighter medics. Others will self-dispatch with wounded in patrol cars.
Fire begins making multiple requests to enter. Radio interoperability problems prevent police and fire from communicating with each other. Firefighters tend to hold back for approximately a half-hour before they attempt to self-deploy, causing confusion at the CP. At some point, fire is eventually cleared to enter the structure. The wounded and the dead are transported.
Crowds begin to form early. If this is a school, frantic and highly emotional parents arrive. Some attempt to enter the school. Many angrily demand information from the officers attempting to hold the perimeter. The media is gathering and may not acquiesce to requests to congregate at the CP. SWAT formally clears and the building is evacuated, sometimes taking hours to complete. The investigation begins.
The Police Focus
The police focus to date has generally been to mass a number of officers—generally four or five—with the intent of moving in formation to interrupt the suspect’s killing. Once the suspect is confirmed to be down, law enforcement then conducts a sweep for possible additional suspects. When the SWAT team deploys, a more thorough search is then conducted. Missing from this law enforcement centered approach is what to do with the wounded.
Fire personnel currently play little part in law enforcement’s view of Active Shooter response. The overall event is a wider problem, something that a police-centric solution cannot solve. By viewing it as a public safety event, the dramatic benefits of an integrated response with police and fire working synergistically can be achieved.
There are two simultaneous and time-competitive processes at work: 1) the suspect continues to inflict wounds as long as he perceives he is free to do so and 2) the wounded are in the process of dying. Once the shooting stops, the emergency is not yet resolved. The wounded are in a time-critical race for survival.
The triage protocol lists four categories. Expectant—the victim is dead or is unlikely to survive. Typically, one-quarter to one-third of those who are shot eventually perish. Immediate—the victim requires immediate medical attention, and is likely to survive if treated within 60 minutes, or the so-called “Golden Hour.” Delayed—the victim’s injuries are severe and may be life-threatening, but are not expected to deteriorate significantly over several hours. Minor—the victim’s injuries are not expected to deteriorate over several days given basic first aid.
Patients in the “Immediate” category are critical and can tolerate very little delay. They must have advanced trauma care within one hour of suffering their wound—not within one hour of the police arriving, the so-called Platinum 15 minutes. For example, U.S. Representative Gabrielle Giffords was on the operating table within 53 minutes of being shot, something her neurosurgeon credited with saving her life. Stabilizing and rapidly transporting the “Immediate” patients is where the life-saving continues.
Stopping both processes—the wounding and the subsequent dying of those who can be saved—must be nearly simultaneous priorities, i.e., the police rapidly interdicting the suspect is Priority 1 and the police facilitating fire personnel instituting their MCI protocol is Priority 1A.
Changing the Response
We must collectively enlarge the focus and change the response. Firefighter-paramedics must be granted early entry and access to the wounded. Only law enforcement can facilitate the rapid entry of fire personnel into the structure and the collection of the wounded. This is a criminal mass-casualty event, and fire’s Mass Casualty Incident protocols are proven in rapidly transferring the wounded to advanced life support facilities. Far from being difficult to achieve, the results become a natural cooperative effort once both disciplines understand the advantages of this approach.
The Hillsboro, Ore. Police and Fire Departments recognized that changes were needed and rewrote the model of public safety’s response to the Criminal Mass Casualty Incident. The Hillsboro Police had already evolved beyond the multiple-officers formation concept several years earlier in favor of rapid intervention by officers entering from multiple ingress points. This initial collaboration resulted in both agencies merging their talents in support of the comprehensive mission. They sought to jointly answer the question of how to stop innocents from being shot while giving those already wounded a better chance at surviving.
Hillsboro Active Shooter Model
The following list is an overview of the integrated Hillsboro Active Shooter Model. Officers respond to dispatched reports of an Active Shooter. As they arrive, they each park on the same side of the street and purposely leave space for the ingress-egress of fire equipment and ambulances.
The first officers arriving make either solo or two-officer entries at their discretion. Multiple ingress points are employed, converging quickly on the suspect. If there are indicators of the suspect wounding people, the officers rapidly move to interrupt the killing. If there are no indicators, the officers rapidly begin to dominate key architectural features such as hallways, and stairwell exits and elevator banks in multi-story buildings. Fire units stage just around the corner.
As the number of officers inside the structure grows and within minutes of the first officer’s entry, a supervisor (or officer) selects and broadcasts a location for a Casualty Collection Point, detailing two to four officers, as needed, to secure it. A Joint Command Post for both fire and police is established. Officers arriving at this point act as fire escorts or external ingress/egress security. Officers may ride in the fire units or lead with a patrol car.
As some officers continue to locate the suspect(s), others begin transporting the wounded to the CCP. Officers apply a tourniquet to anyone with uncontrolled extremity bleeding prior to moving them. The obviously dead are transported last. Once the CCP is declared to be sufficiently secure, fire personnel make entry and set up their MCI protocol. A fire officer and police officer (Hall Bosses) link up inside. This is an interior branch communicating each others’ needs, e.g., body counts, security, etc.
Officers secure the perimeter. As the number of officers from outlying allied agencies increases, the security of the perimeter improves. Ambulances begin to receive multiple wounded, generally transporting two immediate and one delayed. Minor patients are held until the severely wounded have been transported.
Implementing the Integrated Response
The City of Hillsboro has conducted 10 large-scale scenarios over a year-long period, including six scenarios run in a multi-story Middle School and four scenarios in an unoccupied new five-story hospital. These realistic exercises tested and validated the potential success of the integrated Active Shooter Model. Here are the exercise results.
Officers located the suspect in under six minutes of the first shooting, with 25 victims requiring varying levels of immediate medical aid. The CCP was established within 10 minutes of the shooting. Fire entered the CCP four minutes later, beginning their MCI protocol. The 16 wounded (including six immediate, six delayed, and four minor patients) were transported within 40 minutes of the shooting. By comparison, it is not unusual for fire to make formal entry into a structure more than one hour following initial dispatch.
Some flexibility is required by both disciplines to integrate the response. The challenge for police—especially supervisors and mid-level command officers—is to facilitate the early introduction of fire’s lifesaving MCI protocols through training. This instruction emphasizes medical reality: the sooner the wounded are delivered to fire personnel, the greater the chance of saving the injured.
The challenge for fire command, especially at the executive level, is to accept the concept of introducing their personnel into a reasonably secure but not pristinely safe environment (although police officers would argue most police activities are safer than entering a burning structure).
Audio recordings of events where police officers, in frustration and anger, are repeatedly pleading over the radio for ambulances to somehow appear through the sea of police units choking the streets can be a thing of the past.
Instead, it is possible for the worst of the wounded to already be on their way to the trauma centers, medically stabilized by paramedics, well within 30 minutes of the initial police entry. This is accomplished through an integrated public safety response meeting the mutual goals of interrupting the wounding process and gaining rapid treatment for the wounded.
In Part Two, we will cover the priorities in the response and whether TEMS or TCCC are the right answer.
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 email@example.com.