School Shootings: An EMS Perspective

1. 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

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

3. 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

4. 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.

5. The Problem: Looking at the past decade • > 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.

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

7. Are deaths due to school shootings on the rise? Total Shootings Fatalities

8. Who dies in school shootings?

9. 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

10. The Start????Columbine High SchoolApril 20, 1999

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

12. Other School Shootings in PA Sept 17, 1996 Penn State University Jan 7, 2006 Bishop-NeumanJs/Sr High School Williamsport Oct 2, 2006 West Nickel Mines Amish School Nov 13, 2013 Brashear High School., Pittsburgh

13. Who could do this kind of thing?

14. 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

15. The Shooter: The Truth by Generality • No clear cut stereotype • Variable motives • Single vs. Multiple Shooters

16. 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

17. 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

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

19. The Role of EMS in School Shootings • Lessons learned from military and civilian events • Interagency planning and cooperation • Preparation is paramount

20. “By failing to prepare, you are preparing to fail”Benjamin Franklin

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

22. Planning is NOT training

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

24. Staging: Are You The Secondary Target? • Vary Staging Sites with Training • Screen Area For Obvious Dangers • On Site Security

25. So Here You Are……

26. Your Response Must Be Swift and Intentional • Rapid Assessment of Needs • How many ambulances? BLS? ALS? Helicopters? Buses? • Notify hospitals to activate disaster system

27. Safety Zones: An Introduction to Tactics • Hot Zone • Warm Zone • Cold Zone • Hot zone may vary

28. As The Cavalry Arrives • Multiple Vehicles • Multiple Weapons • Lots of Adrenaline • Establish unified Incident Command • Establish Perimeters

29. So Does Everyone Else… • Parents • The Press • Walking wounded • VIPs?

30. “Don’t worry Billy Bob, I’ll get ‘em”

31. 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

32. EMS Response: Who should be first up?

33. Primary EMS Response:Tactical EMS? • Knowledge of Tactics • Ballistic Protection • Role of “Front Line Triage” • Response time • Dedicated to their SWAT team

34. Tactical Emergency Casualty Care: Merging Functions • Additional training for non-tactical EMS providers • Protective equipment • Beyond the concept of staging in the cold zone

35. 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

36. The Hartford Consensus : THREAT • Threat suppression • Hemorrhage control • Rapid Extraction to safety • Assessment by medical providers • Transport to definitive care

37. 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

38. 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?

39. 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

40. Entry and Egress: Secondary Devices • Booby traps • Secondary Shooters • Pre-planned Secondary Targets

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

42. 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

43. Typical Injuries • Firearm related wounds • Blast Injuries • Falls • Burns

44. Treating the Victims • Physical Injury • Psychological Injury • Family and Friends

45. 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

46. 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

47. Questions?