There should be a guiding principle in the implementation of any given policy and/or procedure that embodies the principle of “do no harm.” For example, if your department’s policy or procedure is likely to lead to a negative impact on patient outcomes, then it is time to rethink it.
There is a growing opinion that it is time to rethink the rigid adherence to the diamond formation for rescue task force (RTF) movement during active shooter hostile event response (ASHER) incidents.
The idea behind the diamond formation is to ensure that the medical RTF members – primarily fire/rescue personnel – have a surrounding protective envelope in which to move, work, treat and extricate casualties in a warm zone environment. This environment we call the warm zone is where there is no active or direct threat, but the area is not totally secured by law enforcement.
The diamond formation has a place and is totally appropriate for certain situations, such as transiting through a mall with multiple injured victims in multiple locations when the shooter is still at large in an unknown location.
The diamond formation is a tactic, not a strategy, nor should it be a rigid doctrine. There are many situations in which the diamond formation will limit the capability of responders to perform a rapid assessment, initiate life-saving interventions and extricate victims to the external casualty collection point.
The diamond formation is logistically heavy and typically requires four law enforcement officers with an engine company (3-4 firefighters/EMS providers). That is close to a 1:1 ratio. It is also a very slow way to manage a mass casualty incident. This is especially apparent during a scenario in which a single individual shoots several people but is now barricaded. It would make sense to use several law enforcement officers to post security on the threat, as well as posting security at doorways, but allow the medics to free range inside the secured area to rapidly triage, treat and extricate victims.
Rescue strike force
In a recent comparative exercise, the Sacramento Fire Department compared standard RTF tactics to what they call a rescue strike force (RST) approach. The RST uses only the amount of LEO escorts needed in a secure corridor while the rest are addressing the threat areas. They used 26 victim role players in an environment similar to the Pulse Nightclub, and they were required to enter, triage, treat and extricate all victims over 200 feet to an external casualty collection point.
There were a total of 20 firefighters involved in the drill. The standard RTF approach took about 45 minutes to get all of the victims extricated, compared to less than 12 minutes for the more nimble secure corridor/RST approach. The fastest team treated and extricated all victims in less than 7 minutes. Those are numbers that can have a significant impact on the survivability of penetrating trauma victims. I want to thank Chief Eric Saylor for sharing some of the incredible work that he and the Sacramento Fire Department have done over the years.
Splitting up
In a recent ASHER exercise, we created a complex hostile, disgruntled employee workplace scenario with multiple shooters and over a dozen casualties spread out over several hallways and rooms. We ran 24 iterations of the scenario over 4 days that included close to 600 local law enforcement, fire and private EMS responders.
Once the threat was neutralized and a quick search by the police contact teams revealed no other threats (no bad guys, no bombs), the whole area was appropriately deemed a warm zone by law enforcement. Multiple RTF teams were requested to enter the scene and begin the process of triage, initiating life-saving interventions and then extrication to the external casualty collection point.
We found time and time again, that both the law enforcement and fire RTF members were hesitant, if not adamant, about not splitting up to manage multiple casualties in multiple locations. Basically, there were eight people managing one patient at a time, one room at a time, even though all knew the threat had been neutralized.
Defensive approaches
Current ASHER RTF training emphasizes that law enforcement is to always stay with your RTF medical partners. We should take a broader look at this idea. The underlying principle is that law enforcement will provide security for the RTFs, but how that is accomplished may take on different forms instead of a diamond formation, or in other words, a security escort. The other goal is to create a safe haven or what some call a beachhead and/or security corridor. NFPA 3000 is currently being updated and in the newest revision, the terms “protected island” and “protected corridor” are being defined and advocated.
A security escort is recommended during movements through open terrain which is not under complete control of law enforcement. An escort is composed of law enforcement officers forming an outer ring around fire/EMS providers. In a real-world example, an escort would be necessary as the RTF moved through the open areas of a mall or schoolyard.
An alternate form for securing fire/EMS is the security corridor. In this approach, officers will spread out along a particular area and post up at key positions while fire/EMS freely moves within that area. An analogy between the escort and the corridor can be described as man-to-man versus zone defense.
In the escort model, specific law enforcement officers are responsible for specific fire/EMS personnel as they move from one location to another. However, once the crisis site is reached, officers could and should move to cover specific areas rather than specific personnel. Fire/EMS must stay within the corridor to remain secure. Once the corridor is established, law enforcement officers can and, in some cases, should break apart from their original Fire/EMS counterparts while maintaining security.
The advantages of a security corridor approach
Transitioning into a security corridor from a security escort has several advantages. First, depending on the area, only a few officers may be needed to create a security corridor. This frees up other officers to help conduct life-saving interventions and casualty evacuation.
Second, the corridor allows free movement for the fire/EMS personnel from the point of wounding to the casualty collection point. RTFs do not need to reform the security bubble for each movement between the two areas.
During the recent exercise, we saw several LE officers refuse to give up the security escort within the security corridor, claiming that their previous training directed them to never leave their initial escort until all casualties had been evacuated. Maintaining a security escort within a security corridor is redundant. Redundancy leads to inefficiencies, and inefficiencies lead to increased mortality rates for those wounded in an ASHER event.
Another approach that is very common is to have the law enforcement personnel only perform force protection/security and not anything else. That makes sense in certain situations, but not in others. Having everyone working together to save lives while maintaining a safe environment should have an impact on getting victims transported sooner.
Another area where there is wide variability across the county is in specific benchmarks to be transmitted to all disciplines during an ASHER event. Radio announced response benchmark events/activities should become part of ASHER incidents and communicated when met. Dispatch can repeat these benchmarks so that all personnel on scene and responding know the current situation status of the event.
Response benchmarks options (not necessarily in chronological order):
1. Declare ASHER event
2. Establish command (who is IC)
3. Contact team (X) has entered the building
4. Suspect(s) is (in custody/down): provide full description including clothing, weapon, etc.
5. Warm zone established: describe boundaries (this drives RTF actions)
6. Perimeter secured: describe boundaries
7. RTF (X) has entered the building
8. Casualty collection point established: describe location
9. All red/yellow/green casualties evacuated
10. All RTFs have exfiltrated crisis site
11. Secondary search initiated
12. Secondary search completed – scene is now cold and ready for crime scene investigation
In summary, the science of active shooter response is a relatively new one. While the best of intentions are behind our current training and procedures, we need to critically look at what we do and why. If there is a better model or a modification that may save more lives, then it only makes sense to examine it.
These types of horrific events are becoming more commonplace and we need to remember that the time between injury and surgery for victims has a direct outcome on survivability. “Speed saves” and “light is right” should be the direction we take, while keeping all responders safe.
NEXT: Reducing variability in active shooter incidents: 4 ways to ensure effective response
