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Internal Casualty Collection Point or Rescue Teams? Integrating Police and Fire/EMS Within the Active Shooter Response

by George on August 16, 2014 09:55

Active Shooter events will likely be with us forever.  If it is not the mentally ill seeking a sense of aggrandizement or revenge, it will be the Salafist bent on the world caliphate (and, unfortunately, our Mumbai and Beslan experiences are coming) or some other form of terrorist act (or act of war).  In the past, the response has been seen solely as a law enforcement response.  It was law enforcement’s job to get to the scene as early as possible to stop the suspect from harming any additional victims.  After the scene was determined to be completely safe—often taking more one-hour—firefighters and/or their EMS counterparts were then permitted access to the victims who had been bleeding and dying from the moment of being shot.

Recognition is growing that the Fire Service with its Emergency Medical Services (EMS) capabilities brings life-saving skills that are just as necessary to preserve life as that of stopping the suspect’s rampage.  Active shooter incidents now become a “Public Safety” response, integrating the police and fire/EMS services into an efficient and highly effective reply to any criminal mass casualty incident.  How Public Safety responds to this high casualty incident means the difference between life and death for not only those victims who have not yet been shot or injured, but also for those who are wounded and facing life-threatening injuries.

In any response method, time has proven that the less complexity a method involves, the more likely it will work.  Simplicity equals reproducibility.  Complexity creates friction, and friction is the enemy of operational success.  Likewise, a system of response that is highly intuitive and requires personnel to operate within their existing skill and knowledge sets is more likely to be successful.  A response method should be selected based upon its initial degree of training difficulty and expense, as well as the intensity and cost of sustainment training necessary to maintain the capability of personnel to effectively respond.  

 
Two Primary Response Methods

There are two primary methods of integration being implemented across the country:  The use of a secure Internal Casualty Collection Point (CCP) in a “warm zone” inside the structure, or the use of Rescue Teams (RT, sometimes referred to as a “Rescue Task Force”) to bring the wounded out of the structure to a CCP in a cold zone.  

  •  Internal CCP:  This is a proven life-saving option where the wounded are quickly moved to a secure area within the structure for purposes of quickly assessing and categorizing (triage), rapid control of bleeding or clearing of air passages (treatment), and delivering that person to a definitive medical care facility (emergency surgery in an operating room) as quickly as possible (transport).  Fire personnel, escorted by armed police as security, enter the secure CCP and implement their Mass Casualty Incident (MCI) protocols to process and transport the most critically wounded as quickly as possible to life-saving care. 
  • RT:  The team consists of 2-4 police officers and 2 paramedics who are trained to move as a team into a cleared hot zone (although proponents of the RT state that the team operates in a warm zone, the requirement of ballistic armor and moving through cleared but unsecured areas argue against that assessment).  As the team encounters wounded individuals, the paramedics stabilize and then transport the injured person in a tactical manner to a CCP that is secure, generally outside of the structure.  The team then re-enters the structure, tactically clearing its way to the next victim where the team’s efforts are repeated until the structure is cleared of wounded. 

Time is the enemy of the Active Shooter response.  The more time the suspect has privacy and can safely hunt his victims, the greater number of casualties there will be.  And the longer it takes to get the wounded to definitive medical care, the more who will suffer a preventable death.  Both methods operate under the same time constraints:  some of the wounded will die no matter what type of medical intervention they receive.  Most of those who will inevitably die will expire within minutes of being shot.  Others who are seriously injured may die from uncontrolled blood loss even though they might be saved by early surgical intervention (e.g., the TSA agent who was murdered on November 1, 2013 at Los Angeles International Airport).  Others can tolerate delays of hours before their injuries are life-threatening.  It is the group of the seriously injured who will benefit most from life-saving represented by the efficient and effective integrated police-fire response.

 

Internal CCP, or Rapid Response & Treatment Method (R2TM) Dual Priorities

The R2TM response employs an integrated response of police and fire/EMS to achieve simultaneous dual life-saving priorities:

  • The rapid response by police to mitigate the imminent threat to life of the suspect(s).
  • The mitigation of the wounded through the safe and rapid introduction of fire/EMS personnel into the scene to begin early Mass Casualty Incident (MCI) protocols resulting in the rapid transport of the injured.

How the R2TM response works

The R2TM program operates under the concept of a time-limited response.  Upon notification of a criminal mass casualty incident in-progress, on-duty officers immediately respond and make entry, swarming the structure through multiple ingress points.  These officers, singly and in small teams of two or three (as officers begin arriving simultaneously) quickly move toward threat indicators (shots, victims fleeing, etc.), generally to the last reported position of the suspect.  The intent is to mitigate the threat of the suspect, to control corridors and key architectural access points, and limit the mobility of the suspect(s), denying access to additional victims.

Fire personnel simultaneously stage nearby.  Two crews merge into one apparatus with their MCI trauma gear.  The first arriving apparatus delivers two fire lieutenants and six to eight firefighter/EMTs/paramedics.  Depending upon the initial intelligence as to the number injured, this can expand to another—or even several—apparatus with combined crews. 

What is at first a very limited number of responding officers who are moving toward the indicators of threat or the last reported position of the suspect(s) typically becomes a wave of officers who are responding from more distant beats and nearby jurisdictions.  This typically occurs within 5-7 minutes of the first officer entry.  This late-arriving wave of officers transitions from suspect mitigation to victim life-saving tasks. 

  • A police supervisor takes and secures a Forward Operating Base (FOB) within the structure.  Security is established by up to three officers.  The FOB permits better utilization of interior resources prior to the establishment of the Unified Command (UC).  The FOB supervisor coordinates responding officers, directing responding officers to either make entry or, when there are sufficient numbers of officers involved in suspect mitigation efforts, to respond to Fire Staging.  It is likely the FOB will transition into the Casualty Collection Point (CCP).
  • Responding officers not already involved in suspect mitigation efforts now report to fire staging to act as “Fire Security Teams.”  These security teams will provide security during ingress of fire personnel into the CCP.
  • A hasty Unified Command is created by the linking up of a Battalion Chief and Watch Commander or shift supervisor.  This occurs at the Fire Stage location.

As the location of the suspect is narrowed down, some officers pursuing mitigation efforts will become redundant.  These as well as additional officers entering at this point transition their focus of efforts to life-saving efforts for the wounded.  As soon as the location of the CCP is declared by the FOB/CCP supervisor, they begin moving the wounded to the secured CCP in the warm zone.  If there is uncontrolled bleeding, the officers may tourniquet the wound before dragging or carrying the patient to the CCP.

Firefighters, escorted by armed officers, make entry into the CCP, ideally within 10-15 minutes of the first officer’s entry.  Ambulances are brought forward even as suspect mitigation efforts continue, protected by the officers on the security teams.  Fire implements its Mass Casualty Incident (MCI) Protocols, a process they are expert in and require no additional training to perform well.

The CCP concept is a functional option for many practical reasons:

  • Police and fire remain in their respective skill and experience swim lanes.  There is very little cross-training required.  Initial training focuses on a slight paradigm shift for officers.  While traditional police Active Shooter response training has solely focused on locating and stopping the threat, police are quickly trained on requirements for establishing an effective CCP for fire/EMS to conduct their MCI.  Other than this nod to extra-police duties, the disciplines—and their training—remain intact.  Police mitigate the suspect’s threat (verify he is down by suicide or third-party action, shoot him, verify he has barricaded or has fled).  Police conduct security efforts to protect fire personnel as they transition inside to the warm zone/CCP and as they conduct their MCI protocols.  As we’ve seen in incident after incident, officers carry and drag the wounded when EMS is delayed—the CCP concept formalizes this naturally occurring behavior, requiring armed officers to transition the wounded to the CCP.  While suspect mitigation efforts are on-going, firefighters enter the warm zone (without the need of ballistic protection) and conduct their MCI.  Protected by police security teams, ambulances pull up to the CCP entrance to receive the wounded ready for transport and are transported to a definitive care facility.
  • It is intuitive.  Once the concept is explained to line, supervisory, management, and command personnel, the concept becomes intuitive, lessening the degree of training perishability that is inherent in any response method.  As solutions become more complicated, perishability increases, creating a greater need for recurring training and greater budget expenditures.  There are no formations to learn and forget for either the police or fire.
  • The CCP concept is proven.  The early establishment of the CCP is a proven concept in military combat operations and permits rapid triage, treatment, and transport for the wounded.  If 18-year olds in combat can understand and function with this concept, police officers will easily function and make it work.  The 2011 shooting of Congresswoman Gabriel Giffords along with the six dead and 12 additional wounded is an example.  A married doctor and nurse already on-scene immediately set up triage, and because the location was in a parking lot, fire personnel and ambulances had immediate access to the wounded.  Congresswoman Giffords was operated on within 53 minutes of being shot, saving her life.The early establishment of the hasty UC is likely.  Unified Command between police and fire is facilitated and established as early as the two field command elements can respond to the Fire Stage location.  This is an established priority for this response method.
  • Unified Command is not required for suspect mitigation efforts, the CCP to be identified, or for patient transfer to the secure CCP.  While Unified Command is vital to the success of the overall response, it is not required for suspect mitigation efforts, the formation of Fire Security Teams, establishing a Fire Stage (where two fire companies merge with all of their MCI gear into one apparatus), or  establishing a secure CCP.  The UC is not critical to initial police life-saving efforts until the release point where fire is permitted to make entry into the CCP while protected by the security teams.  The UC gives fire permission to make entry, complying with fire protocols within the Incident Command System (ICS).
  • The Incident Command System becomes a function of facilitation rather than an obstacle to life-saving.  Initiall responding officers make independent entry into the structure singly or in twos or threes.  As additional officers arrive there becomes an obvious point where additional personnel are not necessary to suspect mitigation efforts.  Some who are inside the structure will turn to patient transfer to the CCP.  Others arriving at this point will become part of the Fire Security Teams.  Fire personnel have already staged and completed their integration of crews and equipment into the primary response apparatus.  It is only now that the ICS catches up with the incident and the need for command and control is exercised in releasing the security teams and fire personnel to make entry into the CCP.  By now the hasty UC, consisting of a Battalion Chief and a police supervisor or Watch Commander, is up and sufficiently oriented to make the call.

Where problems are experienced within the R2TM/Internal CCP method is primarily due to training scars from prior response methods requiring the thorough searching of every nook and cranny of a structure before concluding that is clear and "safe."  Training must stress to officers that their job is to create a reasonably secure "warm zone" rather than a safe "cold zone." 

 

How Rescue Teams Function

The Rescue Team (RT) functions under the concept of a time-limited response.  Officers make entry, either through rapid response (one or more officers interdicting the suspect(s)) or by formation.  Officers then locate the wounded and twice sweep a corridor leading to a CCP on the exterior of the structure, searching and clearing each room and access to the corridor.  The Unified Command Post (UCP) is notified that the corridor is clear and ready for patient extraction.

Officers and trained and equipped firefighters/EMS report to the UCP.  Teams of two firefighters who are specially trained in small unit movement and equipped with ballistic protection (helmets and vest) are assigned to a team of two to four officers.  Multiple teams are designated and prepare for entry.  As soon as the UCP is notified the corridor has been twice-cleared (now considered a “warm zone”), the RTs move to the structure and make entry.  Each RT moves as a team utilizing specific trained formations that change given the architectural layout, possible threat area, or some kind of obstacle.

RTs encounter patients and treat them in place, stabilizing them, and then drag or carry them while guarded by their law enforcement counterparts.  After moving the patient to the exterior CCP, the RT returns, moving in formation, to the next patient.  At the CCP, firefighters/EMS perform their Mass Casualty Incident protocols the patients are transported in order of the severity of their injuries.

While Rescue Teams may function once they are finally established and begin operating, however, there are a great deal of unanswered questions and problems surrounding this concept that has been tried and failed in the past:

  • RTs bring EMS skills to the point of wounding.  For a patient who is bleeding severely from multiple gunshot wounds (GSW), having two paramedics, each having an MCI backpack filled with medical equipment, is surpassed only by the patient already having arrived at the trauma center.  However, Mass Casualty Incident protocols were developed to efficiently process multiple trauma patients into the definitive care system as quickly as possible.  Delaying transport to a trauma center by two paramedics “staying and playing” causes other patients to be denied these EMS professionals’ help.  The critically wounded are best served in this instance by minimal EMS intervention and rapid transport to a trauma operating room.
  • A limited number of RT-qualified personnel will be available at any single incident.  A number of agencies boast they have at least one, and sometimes two qualified RT firefighters on every shift in their city.  Those personnel, first, must respond city or county-wide to the incident.  If there 20 patients, 8 immediate and 12 delayed, how long before all 20 are triaged with one or possibly two teams operating in the incident?  Triage cannot efficiently occur if patients are being encountered individually by EMS first responders.  The question should be, “How can we efficiently transition patients into the MCI process?”  The only answer is to get them quickly into the CCP for MCI processing into the Trauma Center. 
  • RTs serve no function that responding officers do not, and officers accomplish the same task much more quickly and with fewer resources.  Other than the control of arterial bleeding (which officers are capable of controlling with tourniquets), patients are best served by their rapid transfer to the CCP and into the MCI process.  Studies demonstrate that any delay in the arrival of a patient to definitive medical care results in a lower survival expectation.  Patient survival depends upon a systematic triaging and transport based on medical need rather than individual diagnosis of wounds and stabilization at the location of wounding.  Officers are already operating in the hot zone within the building.  Officers, singly or in pairs, can more easily and quickly transfer patients to the CCP than can a slow moving tactical formation.  This natural police behavior requires no direction by higher authority as evidenced in many incidents where officers take the initiative to move patients to EMS personnel rather than wait for fire and EMS to be released into the scene.  Every minute waiting for command direction is another minute the victims are bleeding out.
  • RT personnel linkup procedures are unclear.  In many RT scenarios, the team members are already in kit and linked up, and appear at the ingress point of a building.  Where did the eight teams of four officers and two paramedics each find each other, get assigned into teams, and who assigned them to make entry within minutes of the first officers entering?  In the midst of the chaos and urgency of an actual event, escort officers and RT firefighters must respond from their respective locations (their stations, the field, from home), have a rally point (the Command Post once it is set up), receive assignments, stage until the CP is informed that a particular corridor or area has been twice swept, and then make entry when released by command.  This is unlikely to happen in the early response stages.
  • Command Posts (CP) often require a prohibitively long delay in being set up.  How long does it take in the real world before the average CP is established and, importantly, functioning?  The CP not only must be established, but the personnel manning the CP must quickly get up to speed and orient to an overwhelming amount of information, enabling them to then process detailed intelligence from interior officers.  Someone in the CP must then divert their attention from gathering and analyzing the information to attend to forming and releasing the RT to respond.  This takes time the wounded do not have.  Without a functioning CP, the RT cannot come into existence and cannot be dispatched.
  • The RT model assumes there is clear and early communications between the interior units and the CP.  The RT model assumes RT personnel will be on-scene and linked up early in the incident response.  It also assumes that communications with interior units and the CP will be established early and will be clear regarding the status of the operating area in which the RTs will operate.  An RT will not get the go-ahead to proceed without clear communications regarding where they are needed and their route of travel.  If communications are confused or the radio repeaters shut down due to call volume (a common occurrence), insertion of the RT must be delayed.  The RT’s dependence upon early and clear communication from interior units is a major vulnerability to this concept.  Hinging this much on such a fragile variable is not tactically nor strategically wise.
  • When communications inevitably go down or are swamped, how are the RTs controlled?  These incidents typically put a heavy demand on available radio frequencies.  It is not unusual that radio repeaters shut down during the midst of suspect search operations for many seconds or even minutes.  Sometimes the structures themselves block radio communications and hamper operational tempo and coordination—especially in top-down management environments.  RTs require strict coordination from the CP while these incidents by their very nature subvert clear communications.
  • Command and Control of RTs may be impossible due to the confusion and information overwhelm experienced in these situations and problem with communications.  RT models permit teams to enter a section of a building only after the corridor(s) and adjacent rooms have been twice-swept.  Given the mass confusion as well as the contradictory reports and misinformation over the radio (“All units, reports of a second suspect, description to follow.”), as well as the information overwhelm that will initially be presented to the Command Post, how will the CP: 1) Be established in time to be a factor in the wounded’s survival?  2)  How will the CP assign team members to teams in a timely manner?  3) How will the CP determine what is a warm zone and what is not with any degree of accuracy?  In the interior of many buildings it is easy—and common—to become disoriented to the cardinal directions.  How will the officer be certain that the “west corridor” is properly identified?
  • It takes too much time to sweep and clear an area twice before permitting the RTs to enter.  From the moment the individual is wounded, he or she has been bleeding out.  Some of these people are running out of time.  They have no luxury for the time it takes to sweep and clear an entire hallway and each room leading to it, the same number of officers could have secured the hallway and transitioned all of the wounded to the CCP.
  • RTs are resource heavy.  Even the leanest RTs require two police officers and two RT-qualified EMTs/paramedics.  In an incident where five teams are needed due to the number of wounded, where will the ten equipped and trained firefighters come from?  How long will it take for them to report to the scene when off-duty?  It must be remembered that within 20 minutes of the first responding officer, it is not unusual for public safety traffic jams to lock up every surface street for blocks—late arriving firefighters/EMS may have to walk for blocks to the get to the UCP before being assigned—after they respond to their station for their turn-out gear.
  • RT members require ballistic Personal Protection Equipment (PPE).  This PPE represents a large budgetary expense:  minimally ballistic vests (sized to each individual), ballistic helmets, and ballistic eye protection.  Some teams are each being kitted out with TEMS backpacks.  Maintenance and storage issues soon arise.  Where on the truck is this PPE carried year round (especially when each vest and helmet is fit to an individual)?  Who maintains it?  Who tracks the expiration dates of the PPE for replacement?  Due to the lack of incidence, this PPE may be carted around for the duration of that firefighter’s career and never be used.  As promotions, injuries, and retirements occur, additional ballistic PPE will be required for the new RT fire members.
  • RTs are actually responding within a “hot zone,” not the advertised “warm zone.”  As in HazMat responses, the hot zone requires special PPE for the technicians to perform inside the affected area, while support personnel in the “warm zone” do not because they are not presently endangered by the environment.  The need for ballistic PPE for the firefighters in the RT argues against the classification of “warm zone.”
  • RT personnel must have frequent recurring training.  Fire personnel are not trained in police tactics and small unit movement.  This is a new skill involving very low-frequency, high-personal threat activities where the likelihood of an individual actually being called upon to perform these tactics is far less than the chance of any individual officer getting into a shooting on a particular shift.  Nothing in the firefighters’ daily work tasks will reinforce this training.  As such, it will require intensive initial training.  The perishability of this training is high and team members must maintain this skill for the duration of their career with frequent—and expensive—sustainment training.  Additionally, as interest wanes or promotions, injuries, and retirements occur, new team members are required to be trained and equipped.
  • Formations are slow and impractical.  Transitioning patients to the CCP for MCI processing is time-critical.  The more people needed to respond to a single location for assignment, be granted permission to enter a twice cleared area, move to the location of a wounded individual, stabilize that individual, and then move back to transfer that person to an external CCP, the more friction there will be, hampering rescue operations.  Four (or six) individuals moving in rigid formations and collecting one patient at a time to transition to a distant CCP is not only inefficient but is time consuming while people are bleeding unattended and in need of a surgeon.

 

Time matters

As Sgt. Craig Allen said, "US law enforcement wasted more than a decade training officers to respond to an Active Shooter in formation and have nothing to show for it.  It's time we move in the direction of life-saving and abandon formations."  This includes formations in any form. 

The concept of early interdiction of the suspect combined with the early establishment of the CCP and transitioning patients through the MCI protocols into definitive medical care as rapidly as is safely possible is a less complex, more intuitive method of response.  It is fast enough to mitigate the most common incident: the lone gunman in a gun-free zone with complete access to victims.  It is also flexible enough to respond to the threat of multiple suspects acting in multiple locations.  And it requires far less recurrent training because there is little cross-training—officer and firefighters are asked to perform their everyday tasks within the model:

  • Police:  Respond to a man with a gun/shots being fired call. 
  • Police:  Provide security against assault.
  • Fire/EMS:  Respond to a medical call with multiple trauma victims.
  • Police and Fire/EMS:  Help people who have been victimized and injured.
  • Police/SWAT:  Perform a final clearing of the structure.
  • Police:  Evacuate and reunification.
  • Police:  Investigate the crime(s).

Rather than recreate a failed tactic and instituting a complicated method requiring expensive equipment that might never be used as well demanding extensive recurrent sustainment training as well, success is more likely when employing a less-complex, more intuitive method.  The integration of police and fire is a life-saving concept that should be adopted and made as simple and as intuitive as possible.  This is best achieved when the police are tasked with police duties and fire with fire duties, and the two disciplines work together to achieve the overall goal of the Public Safety response:  life-saving.

 

My thanks to Jeff Gurske and Roberto DiGiulio for their contributing to the content of this article.