A Fourth of July block party is in full swing on a street notorious for trouble. Sometime after midnight, a disturbance breaks out in a large crowd. One subject pulls out a firearm and opens fire wounding at least three. In the chaos, nobody knows where the gunman went.
As police respond, multiple fire and EMS units stage near the scene. Police officers begin to arrive but cannot find the gunman in an angry, panicked crowd of at least 100 people.
While some officers attempt, with great difficulty, to gain control of the crowd, other officers are trying to locate victims. Three are located. One person is dead, one critically wounded and the other wounded but not serious.
It is unclear if the scene is stable enough for EMS to enter and when PD declares the scene safe, the message is not relayed to EMS units.
During the confusion of radio traffic, EMS is notified that PD is doing CPR on a deceased victim. The fire battalion chief and EMS supervisor desperately attempt to advise the officers to abandon efforts on the deceased and move the other wounded to the perimeter to the ambulances since the scene is not safe. The officers in turn are directed by their command to move the victims to the hospital.
Confused paramedics stand by as a convoy of squad cars blow past them en route to the hospital. The end result is two dead victims and one clinging to life with no suspect in sight.
If faced with this scenario of confusion and poor communication, what could you do to assist the wounded?
How to prepare law enforcement for casualty care
How can officers be prepared to handle casualties in a violent scenario until EMS personnel are cleared to enter the scene or casualties are evacuated to a safe zone with EMS presence?
This is accomplished through knowledge sharing. Many officers already know how to quickly treat immediate life threats in order to prevent loss of life, however, law enforcement often has little knowledge as to how EMS operates at scenes like the one described in the opening scenario.
Knowledge of EMS tactics and expectations can enable officers to assist EMS prior to and after the arrival of EMTs and paramedics. Here is what officers need to know.
Appropriately allocating and deploying EMS resources
As a paramedic, I play “doc in a box” for PD units on a regular basis. I understand my role in those requests and do it happily, but I have noticed a recent trend of requesting EMS super early, such as for a domestic disturbance, in case someone might be hurt.
And that is ok, as many EMS services are usually very busy, and you might be waiting a while for an ambulance if you do not request one early. However, the problem is that the same does not happen in shootings and that can cost someone precious seconds they might not have to spare.
During mass casualty training, EMS is taught to “Order early and order BIG.” The idea is that we can always turn units around we do not need if the scene is not what we were expecting.
So, do not be afraid to ask for as many EMS units you think might be needed or any other special resource such as fire apparatus, EMS supervisors and chief fire officers at a major incident.
Once EMS is en route, it is important to relay deteriorating conditions on scene, like a shootout or vehicle/foot pursuit. This helps EMS determine where and where not to stage and determine staging distance. I personally have staged within sight of the incident when PD was already present, so I was as close as possible when the scene was determined safe. However, if there are shots being fired I would stage farther away.
Information to share with EMS
Sharing information as it is gathered to EMS through dispatch is beneficial for quick, effective patient care and for the safety of those responding.
As police units respond to scenes, they keep an eye out for suspects and vehicles associated with the crime committed who may be heading away as officers are heading in. EMS units are heading the same way and frequently stage within distances where some suspects may choose to hide, so knowing a description of the suspects and the direction of travel goes a long way to ensuring the safety of EMS.
While the first few arriving police units start collecting initial information, they can communicate the number of victims and the best guess at their injuries, which significantly aids in how efficient EMS can get the victim off the scene while providing the best patient care possible. This can be as simple as “multiple wounds,” “unconscious,” or “shot in the chest.”
In addition, the number of victims impacts the response matrix on the fire/EMS side of the response. There is a huge difference in responses to single victim scenes and scenes with multiple victims. Relaying the location of victims as you find them is helpful for obvious reasons but is often overlooked in the chaos.
FAQ about casualty collection points
Here are some common questions non-medical folks have about casualty collection points:
What is a casualty collection point? A casualty collection point (CCP) is a site that is used for the assembly, triage (sorting), medical stabilization and subsequent evacuation of casualties. The CCP is usually located in the warm zone of the incident.
EMS uses CCPs to manage and account for patients at large or dangerous scenes. CCPs are, however, beneficial at smaller incidents too. Think about this: You pepper spray or use your TASER on two people fighting outside a bar and request EMS. Those two people are moved across the street and out of the crowd. You have one or two officers with them waiting for EMS. You tell dispatch to advise EMS you are across the street with the victims. Guess what? You just established a CCP with security in the warm zone of an incident.
Who can establish a CCP? The answer is anyone, but more than likely it will be a fire or EMS unit that decides to have one but in a situation as described in the opening scenario, any officer could have made the decision and coordinated with EMS.
What are good locations for a CCP? The main things to consider are:
- The approximate number of victims;
- Location of victims (spread out or confined to a more general area);
- Status of the incident as a whole (is LE looking for the suspect, clearing the building?); et)
- Suspected location of the shooter(s).
Using this information will help with locating the warm zone, the size of the area to establish the CCP, and whether it needs to be a formal area.
The middle of the street in a warm zone can be a CCP if it can be secured. Examples of areas that can be used are adjacent buildings, garages, driveways, classrooms and open fields if they can be secured by the lowest number of officers.
One last thing to consider is police car staging. If police vehicles block access this delays EMS getting to the scene. Consider having vehicles ready to be moved for EMS access. Also, when selecting an area for a CCP, remember that EMS needs access in and out with ambulances for rapid transport.
What is Triage?
Triage is the systematic classification and sorting of victims to transport the most life-threatening first and deceased last (“worst go first”).
The reason EMS triages patients is to appropriately dedicate resources to the correct victims and ensure they get transported as soon as possible.
Triage is also applied when the number of victims overwhelms the initial response from EMS.
Another scenario might be if LE is delayed getting EMS into an incident due to an active threat, LEOs might be providing emergency care until EMS arrives. Knowing where to focus your actions is paramount for saving the most lives.
How does EMS do it? Most services, but not all, use a procedure called START triage. This stands for Simple Triage and Rapid Transport. The idea behind this is to quickly classify and sort victims and get the worst off the scene the quickest. Classifications include:
- Green: Walking wounded. These are the most minor and anyone who can walk is initially given this color.
- Yellow: Delayed. This is given to people who have non-life-threatening injuries and cannot assist themselves.
- Red: Immediate. Red is used for victims who are unresponsive, confused or show signs of inadequate perfusion (shock).
- Black: Deceased. This is used to classify any person who is not breathing after basic airway maneuvers, has no pulse present, or has injuries incompatible with life, i.e., decapitation. Black tag victims should be left where they are found and moved last. DO NOT expend resources on these victims. Cover with a sheet if necessary. Point out the victims you believe to be deceased and EMS will confirm when the resources are available.
Applying triage and providing initial, immediate treatment
While taking all the above into consideration, you find yourself face-to-face with the victims as your partners secure the scene and search out the suspect. Now what?
Now we employ simple triage methods and treatments to stabilize major life-threatening injuries.
Understanding that most officers are not trained medical providers, the advice offered will be very basic.
Start with seeing if your victim is awake. If the answer is no, check their breathing. If they are not breathing, they are considered deceased (for now) and you should move to the next victim.
If they are not awake but breathing, control major bleeding with tourniquets, QuikClot, bandages, etc.
If the victim is awake, control the bleeding in the same manner previously described. If the victim can walk, have them sit in a safe area.
As EMS arrives, they will retriage the victims but will have an idea of the equipment and resources needed. You have provided EMS a huge assist.
Moving victims and continuing treatment
If after checking the victim(s) on scene you find yourself in a position where EMS is still not cleared to enter, you can do more.
Some options exist and none of them are difficult to accomplish.
First is to identify a warm zone and set up a CCP with a protection detail. Then move the victims to that area and EMS can now enter the scene. The second option is to move the victims however you see fit to the perimeter and transfer them to EMS.
Now that you have the victims moved to the CCP, continue to treat them as necessary until the arrival of EMS. Familiarize yourself with the use of tourniquets, which are needed for extremity wounds. QuikClot is applied to wounds where you cannot apply tourniquets. Chest seals are used for wounds located on the chest. Beware that the majority of chest wounds usually have a larger exit wound located on the back.
None of this must be fancy, just providing some type of first aid can make a huge difference. Hemorrhage is the leading cause of death in shooting victims. Giving a report of what you know, no matter how little or how much, about the victims to EMS is an essential part of transferring care and information sharing.
In my opinion, shooting victims should never be transported by police car to a hospital. How an officer-down situation is handled, on the other hand, is up to the police community, although my opinion does not change much as I know just how effective early advanced life support can be.
EMS expectations of LE protection teams
The expectations are few but important to consider from the view of EMS. We are aware that LEOs are not medically trained so please keep in mind that EMTs and paramedics are not tactically trained. Our expectations are:
- Safety: Reasonable safe conditions to work in and move in.
- 360-degree security: This is very important as EMS providers may be moving in and out with victims.
- Clear communication: Operating under the same terms and language so no confusion about directions and warnings occur during an operation.
When faced with a scenario as described above, or an active shooter, employing these simple tactics can create better scene management, communication and ultimately save lives that might otherwise be lost.
As always, you should follow your department’s policies, procedures and protocols, but hopefully, this article introduces some discussion as to whether those policies could be improved.
For any questions, comments, concerns, or find out more about my one-day class on this topic for your department or police academy, email me at email@example.com.
NEXT: The trauma kit, evolved