“Considerations, planning and interagency training should occur around the concept of properly trained, armored medical personnel who are escorted into areas of mitigated risk, which are clear but not secure areas, to execute triage, medical stabilization at the point of wounding, and provide for evacuation or sheltering-in-place.”
Planning for and practicing rapid treatment and evacuation, including who, what, when, where and how it will be carried out.
Using the National Incident Management System (NIMS) and the Incident Command System
(ICS). Accordingly, fire/EMS and LE should establish a single Incident Command Post (ICP) and establish Unified Command (UC).
Fire/EMS, LE and all public safety partners planning and training together.
Including AS/MCIs in tabletop and field exercises to improve familiarity with joint protocols.
Regularly exercise the plan.
Using common communications terminology. In addition to NIMS and ICS terminology, fire department personnel must learn common LE terms and vice versa. Share definition of terms to be used in AS/MCIs and establish a common language.
Incorporating tactical emergency casualty care (TECC) into planning and training. Training must
include hemorrhage control techniques, including use of tourniquets, pressure dressings, and
hemostatic agents. Training must also include assessment, triage and transport of victims with
lethal internal hemorrhage and torso trauma to definitive trauma care.
Providing appropriate protective gear to personnel exposed to risks.
Considering fire hazards secondary to the initial blast if improvised explosive devices (IEDs) are
Considering secondary devices at main and secondary scenes.
Determining how transportation to and communications with area hospitals/trauma centers will
AS/MCIs are volatile and complex. Research and history have indicated that the active risk at most
incidents is over before first responders arrive on scene, or shortly thereafter, but they may also require
extended operations. Extensive planning, recurrent training, and preplanned coordination are all required
for optimal results. Coordinated involvement by the whole community is essential. The public, fire/EMS,
law enforcement, medical transportation, and medical treatment facilities must be engaged cooperatively
in order to maximize survivability and minimize deaths due to AS/MCIs
As you absorb what this document means and consider how it will become operational in your community, keep in mind the following:
1. Tactical medics are attached to a law enforcement unit that is pursuing and neutralizing the active shooter. Tactical paramedics are working in the hot zone. During a mass shooting incident, where the top life threat is uncontrolled hemorrhage, EMTs and paramedics (who are not tactical medics), escorted by law enforcement, should triage, treat (with hemorrhage control and airway management), and extricate patients.
2. Body armor for medical personnel is just one component of team and personal safety. Make sure that a medic wearing a ballistic vest is accompanied by at least three armed and attentive police escorts. A critical part of your personal safety will be following the verbal and visual instructions of the law enforcement escort.
3. An “escort” into the warm zone may be at a dead run, a belly crawl, or a lung-busting ascent of a multi-story high rise. Too many of us are not fit enough to rapidly reach the wounded or crouch in a small area for 30 minutes assessing and treating several patients. Are you ready? Your community expects you to respond in the warm zone.
T - Threat suppression H - Hemorrhage control
RE - Rapid Extrication to safety
A - Assessment by medical providers
T - Transport to definitive care 4
The THREAT concepts are simple, basic and proven. The Hartford paper points out that life-threatening bleeding from extremity wounds are best controlled by use of tourniquets. Internal bleeding resulting from penetrating wounds to the chest and trunk are best addressed through expedited transportation to a hospital setting