School Shootings: An EMS Perspective

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School Shootings An EMS Perspective

• Clifford Neal, D.O., FACEP, FACOP
• Regional EMS Medical Director Seven Mountains EMS
  Council
• Tactical EMS Physician Centre Lifelink EMS

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Disclaimer

• I have no financial interest with any group or
  product mentioned in this lecture.

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Objectives

• Better understand the history of school shootings
  
• Understand the motivation, similarities, or lack
  thereof regarding school shootings
• Improve understanding of the planning, training,
  and equipment required to manage this type of
  event
• Understand the most efficient EMS response for
  the event and for the fallout that ensues

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What would you do?

• Warm, sunny day in May
• A disturbed male student has just opened fire
  with an semiautomatic rifle. First shots
  occurred in an auditorium during a rally, he is
  currently walking classroom to class room.
• The radio is active with multiple police, fire
  and rescue responses
• Active shooting is on-going, and the number of
  shooters is uncertain.

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The Problem Looking at the past decade

• gt 387 school shootings since 1992
• Children ages 5-14 in the US are 13x more likely
  to be murdered with guns in U.S. than in other
  industrialized countries.

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The Problem

• School shootings have resulted in over 50 deaths
  since 2012.
• Majority of states have now experienced at least
  one school shooting

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Are deaths due to school shootings on the rise?

• Total Shootings

• Fatalities

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Who dies in school shootings?
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The ProblemOnce the shooting starts.

• On the average, someone shot every 15 seconds
• Average incident last 12 minutes, 37 last less
  than 5 minutes
• 43 the event is over before law enforcement
  arrives
• FBI law enforcement bulletin May 2013

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The Start????Columbine High SchoolApril 20, 1999
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Greencastle, PA 1764

• 4 Lenape Indians attack the Pontiacs Rebellion
  School
• July 26, 1764
• Schoolmaster Enoch Brown and 11 students killed

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Other School Shootings in PA

• Sept 17, 1996 Penn State University
• Jan 7, 2006 Bishop-Neuman Js/Sr High School
  Williamsport
• Oct 2, 2006 West Nickel Mines Amish School
• Nov 13, 2013 Brashear High School., Pittsburgh

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Who could do this kind of thing?
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WRONG Impressions

• All school shooters are alike
• The school shooter is always a loner
• School shootings are always revenge motivated
• Easy access to weapons is THE most significant
  factor

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The Shooter The Truth by Generality

• No clear cut stereotype
• Variable motives
• Single vs. Multiple Shooters

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The Shooter The Truth by Statistics

• Is often single gunman
• Statistically uses small arms
• Is Male 97 of the time
• Has a history of mental illness
• May be a current or former student(s) at the
  targeted school

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The Shooter The Truth

• Attackers make plans
• Attackers talk about their plans
• Attackers are often encouraged by others
• Attacker has chosen one or more targets
• School staff are often the first responders
• Preventing School Shootings A Summary of a U.S.
  Secret Service Safe School Initiative Report 2002

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The Event

• Short lived (shooting typically over in 12
  minutes or less)
• Confusion delaying 911 calls
• Response of police
• Response of the School Staff

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The Role of EMS in School Shootings

• Lessons learned from military and civilian events
• Interagency planning and cooperation
• Preparation is paramount

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By failing to prepare, you are preparing to
fail Benjamin Franklin
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Preplanning

• Multidepartmental Police, Fire, EMS, Federal
  and State Agencies
• Develop SOPs for response
• Real time communication between communications
  center and emergency personnel
• Safety Equipment

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Planning is NOT training
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Training

• NIMS
• OPSEC
• Multiple Staging Options
• Check for dead zones with radio communications
• Real Response Times
• Access to the building

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Staging Are You The Secondary Target?

• Vary Staging Sites with Training
• Screen Area For Obvious Dangers
• On Site Security

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So Here You Are
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Your Response Must Be Swift and Intentional

• Rapid Assessment of Needs
• How many ambulances? BLS? ALS? Helicopters?
  Buses?
• Notify hospitals to activate disaster system

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Safety Zones An Introduction to Tactics

• Hot Zone
• Warm Zone
• Cold Zone
• Hot zone may vary

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As The Cavalry Arrives

• Multiple Vehicles
• Multiple Weapons
• Lots of Adrenaline
• Establish unified Incident Command
• Establish Perimeters

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So Does Everyone Else

• Parents
• The Press
• Walking wounded
• VIPs?

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Dont worry Billy Bob, Ill get em
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School Shootings MCI With A Twist

• Everyone is a potential shooter until patted down
  and cleared
• Rapid Triage
• Establish safe area for triage and treatment
• Shooting may still be active

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EMS Response Who should be first up?
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Primary EMS ResponseTactical EMS?

• Knowledge of Tactics
• Ballistic Protection
• Role of Front Line Triage
• Response time
• Dedicated to their SWAT team

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Tactical Emergency Casualty Care Merging
Functions

• Additional training for non-tactical EMS
  providers
• Protective equipment
• Beyond the concept of staging in the cold zone

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Why T.E.C.C.?

• While EMS is staged, someone is shot every 15
  seconds
• Entry in to the warm zone may change the outcome
  of this tragedy
• Endorsed by FEMA, United States Fire
  Administration and the IAFF

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The Hartford Consensus THREAT

• Threat suppression
• Hemorrhage control
• Rapid Extraction to safety
• Assessment by medical providers
• Transport to definitive care

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Protective Equipment

• Clearly marked clothing identifying EMS
• Minimal vest /shirt with highly visible markings
• Body Armor for anyone responding in to the warm
  or hot zones

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Advance Triage

• Rapidly performed in the warm zone
• Direct walking wounded to a specific exit with
  hands up and exposed
• Communication with who will be exiting
• Notify Triage Officer of impending litter cases
• Establishing a CCP?

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Casualty Collection Point

• CCP may vary by incident or time
• Warm zone with relative safety
• Should be to the rear of the event, with armed
  coverage
• Access to means of rapid egress

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Entry and Egress Secondary Devices

• Booby traps
• Secondary Shooters
• Pre-planned Secondary Targets

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Evidence Preservation

• Avoid smudging footprints, blood smears/spatters
• Avoid contact with weapons, spent rounds
• Use of paper rather than plastic bags.
• Hands/Wounds

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Treating the physically wounded EMS care in the
cold zone

• Triage tag use
• Similar to other MCIs
• Initial care in the treatment area
• Massive hemorrhage
• Airway
• Respiration
• Circulatory
• Hypothermia, Head
• Injury

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Typical Injuries

• Firearm related wounds
• Blast Injuries
• Falls
• Burns

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Treating the Victims

• Physical Injury
• Psychological Injury
• Family and Friends

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The Lasting Impressions

• Extends well beyond physical injury
• Extends beyond those in direct contact with the
  shooter
• Increase in depression, suicide, anxiety, fear.
• Experiences of EMS providers
• CISM

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In Review

• School shootings are becoming more commonplace,
  fatalities are not
• The changing response of EMS TECC
• Who becomes a victim of the event may extend
  well beyond direct contacts
• After MANY debriefings for mass shootings, the
  recurrent key is PRE-PLANNING and
  MULTI-DEPARTMENTAL TRAINING

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Questions?