Mitigation

The most effective way to minimize the morbidity and mortality of a mass shooting is to prevent the event from taking place. Prevention is primarily an LE issue, but also a tenet of psychological care. The adage states, “The best defense is a good offense,” and it applies to many aspects of crime prevention. We live in a time when firearms are ubiquitous in the United States and many other countries; 2010 National Rifle Association estimates show that approximately 300 million firearms are currently owned in the United States. Firearm ownership is protected by the Constitution of the United States of America, and gun control laws that modify this right have been a cause for debate for decades, and they are beyond the scope of this chapter. Instead, mitigation to reduce casualties must focus on prevention of firearm ownership by potential shooters, aiding LE efforts to find and contain threats before they take action, and to enhance a facility’s ability to deter gun violence.

Profiling the Active Shooter

Research into profiling mass-casualty shooters has proven disappointing. Ideally, patterns or precursors could be identified that would serve as a “red flag” that a person is a threat to carry out such an attack. Important academic work has been done in the area of multiple-casualty violence. However, there remains no specific profile of rampage shooters because of the limited number of events to study. Much effort has been put forth to identify such patterns in serial killers, helping to identify sociopaths early to allow attempts at intervention. Meanwhile, the mental health community has identified only vague similarities in the lives of those who go on to become active shooters, including a tendency to be white males with significant life stressors and variable degrees of psychiatric illness. These traits hardly narrow down the American population to a manageable number, and this paucity of unique traits makes profiling the active shooter very difficult. Because of this, families, friends, mental health professionals, and coworkers are likely to be the best source of information to LE regarding potential threats. Verbal threats, social media posts, and accumulation of firearms and ammunition should be taken seriously and reported to authorities for investigation. Lt. Dan Marcou has theorized five phases of ASE in an effort to aid LE intervention. The first four phases, if recognized, could allow police to prevent an attack ( Box 68-1 ).

Target Hardening

The concepts of crime prevention through environmental design (CPTED) and target hardening involve designing structures and spaces and implementing features that make those places less vulnerable to attack or theft. Active shooters in general choose targets that are considered “soft” or easy to attack because of lack of defenses such as secure access points, armed guards, metal detectors, or other means of prevention. Schools such as Virginia Tech University, Columbine High School, and Sandy Hook Elementary School in Connecticut are prime examples. Implementation of hardening features serves as a deterrent to attack and should be considered ( Box 68-2 ).

Hazard Vulnerability Analysis

When planning for disasters and adverse events, performing a hazard vulnerability analysis (HVA) is a valuable tool that allows a planner to determine the most appropriate delegation of limited resources to plan for hazards with variable levels of probability of occurrence and defensibility. Typically, an HVA is structured to allow the facility to determine which types of events it is most likely to encounter (e.g., earthquakes in San Francisco) and to which it is most vulnerable. Using these calculated likelihoods, agencies can devote appropriate means to protect against certain events. Workplace and school firearm violence should be considered in the HVA for any facility, and the result includes the allocation of funds and time devoted to the mitigation and response to an ASE. Hospitals, and specifically emergency departments, should also include the rapid influx of multiple gunshot wound patients as part of their annual surge capacity training and equipment procurement.

Public Education Drills

The Department of Homeland Security (DHS) and other organizations have developed educational programs designed to educate the public on how to protect themselves during an ASE. The basis for all of these programs is the three options of escape, hide, or fight back. These concepts have been promoted online by an educational video from the city of Houston, Texas, in 2012, titled, Run. Hide. Fight. The essence of the training is to immediately remove oneself from the danger area, as soon as shooting begins. If this is not possible, hide in a secure, protected, locked place in an attempt to deter the shooter. Lastly, and only if confronted with imminent danger, take action against the shooter to subdue him or her. Understanding these concepts is likely to help save lives in future events.

Active-shooter drills are also a critical aspect of preparation. The DHS and others recommend annual workplace violence drills for schools and workplaces. ASE are extremely uncommon; there are more people injured by lightning strikes annually than by mass-casualty shooting incidents. However, the complexity and frequency of ASE appear to be trending upward ( Fig. 68-1 ). The relatively low-frequency, high-consequence nature of ASE suggests the need for ongoing, integrated all-hazards training for high-threat response. In times of stress, we do not rise to the occasion; we fall to the level of our training.

Schools, workplaces, and public spaces should also develop an active-shooter protocol in the unlikely event that such an incident takes place there. This should include implementation of procedures to keep students and citizens safe. Most commonly this involves immediate notification (public announcement, phone text alerts, auto-calls, etc.), lockdown procedures, evacuation, reaction by on-scene security, notification of LE, and request for prehospital EMS response. In addition, new training programs have been developed for security personnel, including from the DHS and the National Association of School Resource Officers. The manner in which police forces respond has undergone sweeping changes, and the adaptation of EMS response into an unsecured tactical environment continues to evolve.

Law Enforcement and Emergency Medical Services Preparation

The massacre at Columbine High School in Colorado in 1999 was the seminal event leading to a paradigm shift in response to ASE. Prior to this attack, police tactics focused on the concept of shooters-as-hostage-takers who are barricaded, not as mass murderers without demands. The traditional response was based on the “Five Cs” of contain, control, communicate, call SWAT, and come up with tentative plan. At Columbine the shooting took place for approximately 45 minutes with no LE entry, despite uniformed officers being on scene very quickly. As SWAT finally entered the building, the shooters killed themselves simultaneously. Following this, training shifted away from containment and negotiation tactics toward immediate response teams of two to four regular service officers making entry with a goal of immediately neutralizing the shooter(s).

EMS response has also been identified as a critical area in need of reformatted training to deal with ASE. A tenet of EMS training is the concept of scene safety; standing policy in most jurisdictions is that EMS personnel do not enter scenes that have not been declared secure. Because of the chaos, police must often engage in a systematic search of the attack site before the scene can be declared secure, which may take hours to complete. As seen with the 2013 TSA shooting at Los Angeles International Airport, where a wounded agent hemorrhaged to death for 30 minutes while traditional EMS staged just yards away in the safe zone, the ability to enter and provide medical treatment in an unsecure scene could mean the difference between life and death.

This incident and others like it call for enhanced training of paramedics, in conjunction with LE teams, to provide lifesaving medical treatment within, and evacuation from, unsafe scenes. This requires EMS workers to learn tactics and be properly equipped to enter potentially dangerous sites, under police cover, to render aid to victims. This training includes the use of specialized prehospital medical techniques, adopted from military medic training, for use in the civilian world. Tactical Emergency Casualty Care (TECC) is a training concept adapted for the urban, noncombat environment, derived from the highly effective military program Tactical Combat Casualty Care (TCCC). TCCC, currently taught to military medics, has helped to reduce the preventable-combat-death rate to the lowest of any period of conflict in American history.

To be effective, event drills should include all agencies that would respond in a real-world situation. ASE, hostage situations, and other criminal activities with medical casualties have at their core a need for a combined response from police and EMS. Performing well-planned, multiagency active-shooter drills not only tests the protocols put in place but also allows individuals to interact and become familiar with members of other teams. This undoubtedly leads to better coordination and teamwork. Ideally, the first time these agencies work together should not be during a real event.

Hospital Preparedness

The prehospital preparation for ASE has evolved dramatically over the last two decades. Within the hospital environment, an all-hazards approach to disaster response should be modified to also include a large influx of complex, mixed penetrating-trauma victims. For trauma centers, this is likely not much different than the current surge capacity plans for mass-casualty incidents with heavy surgical needs, such as explosions and multiple vehicle crashes. Nontrauma centers should consider being additionally prepared for simultaneous arrival of multiple unstable gunshot victims brought to the emergency room (ER) for stabilization prior to transfer. Recommendations include mass-casualty drills with victims of projectile injuries, procurement of equipment such as intraosseous access devices and rapid infusers, as well as having readily available tourniquets in the emergency department for application prior to transfer.

Prehospital

In active violent incidents such as ASE, responders must rapidly transition from routine to high-threat operations. The initial 5 minutes of response are dynamic and disorganized; however, they are not “chaos.” Certain events can be expected (e.g., elevated external threat to life, delayed and conflicting information, high volumes of anxious but noninjured individuals, and highly charged emotions), which require an aggressive yet flexible mission-oriented mind-set that is best developed through extensive interagency training.

The utilization of the Incident Command System (ICS) and Unified Command (UC) is recommended to organize and control the multiagency response. However, given the short time frame in which most of these events develop, agencies must be able to respond dynamically while the UC is being established. LE officers are universally first on scene for ASE. Moreover, even though the initial tactical response is an LE operation, EMS/Fire must be rapidly integrated in order to minimize loss of life. The goals of response are to minimize potentially preventable deaths by mitigating the threat and effectively reducing the distance between casualty and medical provider.

The immediate response can be broken down conceptually into two mission profiles: stop the killing and stop the dying . Since 2000, LE officers have been trained to rapidly enter the scene and neutralize the shooter(s) in order to stop the killing. Existing data support the rapid entry technique. With the advent of the TECC guidelines, national efforts are now under way to train LE officers to assist in stopping the dying through the application of essential lifesaving interventions such as tourniquet application. Appropriate LE application of tourniquets in AS/MCI should be considered standard of care. The American College of Surgeons recommends utilization of the acronym THREAT (Threat suppression, Hemorrhage control, Rapid Evacuation to safety, Assessment by medical providers, Transport to definitive care) to reinforce and train the TECC principles.

Historically, EMS/Fire have used the “stage and wait” strategy until LE officers declare the scene secure. This is no longer a tenable operational strategy. As mentioned above, EMS/Fire rescue teams are increasingly expected to assume greater risk and operate in the warm/indirect-threat zone. This expectation should not be taken lightly and proper tactics, techniques, and procedures (TTPs) should be in place to limit unnecessary loss of life. Multiple-risk mitigation strategies exist, and it is incumbent upon leaders to develop a response plan, properly equip their teams, and adequately train the new paradigm.

Traditional models of prehospital trauma care have limited application in high-threat response secondary to several assumptions, including that care begins with patient contact, that patient care is the only operational concern, and that penetrating and blunt trauma are similarly managed. Prehospital care in the high-threat environment such as an ASE requires responders to perform four broad tasks: access, assessment, stabilization, and evacuation of the casualty.

Access is a critical task often overlooked in planning and training. FBI data on ASE suggest that a majority of events end within minutes of LE arrival and contact with the perpetrator. Anecdotally, this is supported by review of events in Platte Canyon (2006), Virginia Tech (2007), and Sandy Hook (2012) (personal communication). The tactical situation determines the barriers to and components of each phase of care. Examples of barriers to access include padlocked doors, ongoing violent attack, IEDs, building layout, fire, and high volume of minimally wounded or noninjured civilians.

Responding teams should immediately perform a rapid risk assessment and initiate an appropriate interagency response. It is critical to note that most AS/MCI end upon initial LE contact, but that the scene is rarely declared secure. “Scene safety” remains an important concept for response. However, traditional practices of “staging and waiting” until LE officers have declared the scene clear are no longer standard of care. Agencies must develop integrated response standard operating procedures (SOPs) for operating in warm or indirect-threat zones (i.e., areas where there exist ongoing, though not imminent, threats to the health and safety of the victim and responder).

A variety of indirect-threat and warm zone operational models exist to shorten the distance between first responders and the victims of AS/MCI. In general, the response paradigms can be classified into escorted care or creation of evacuation corridors . The prime example of escorted care is the Rescue Task Force (RTF) model, pioneered in Arlington, Virginia. The RTF is composed of specially trained advanced life support (ALS) providers (note: these are not tactical medical personnel) who are provided ballistic PPE and escorted into the warm zone by armed LE officers. Their primary mission is rapid access, assessment, provision of appropriate lifesaving intervention, and rapid extraction of victims. Alternatively, in the Evacuation Corridor model used in other regions, LE officers preliminarily clear immediate threats, creating “warm corridors” and allowing unescorted EMS/Fire to access and extract victims.

Assessment and stabilization should be performed based upon the principles of TECC. The tactical situation and provider qualifications influence the assessment and stabilization phase. In general, rapid control of potentially life-threatening extremity hemorrhage and rapid evacuation are critical. The TECC guidelines are acknowledged as the standard of care principles for response to high-threat events such as AS/MCI. The TECC guidelines outline combined medical and operational response principles to reduce potentially preventable causes of death. TECC organizes response into three dynamic threat-based categories: direct-threat, indirect-threat, and evacuation or secure zone. The primary goals during direct- and indirect-threat care are threat mitigation, rapid hemorrhage control, and rapid evacuation.

Despite limited comprehensive data, traumatic hemorrhage is the major cause of death in AS/MCI. Properly applied tourniquets are proven to reduce morbidity and mortality from penetrating extremity trauma. TECC guidelines recommend that all first responders, including LE personnel, be trained to use tourniquets aggressively for any potentially life-threatening extremity hemorrhage. Military data suggest that tension pneumothoraces and airway obstructions are the other top-two causes of potentially preventable death in high-threat combat scenarios. There are no corresponding civilian data that confirm similar wounding and mortality patterns. However, given the lack of PPE on most victims of civilian AS/MCI, providers can expect a high volume of penetrating torso trauma.

Triage is a dynamic process that includes an initial sorting of patients, generally during the indirect-threat or evacuation phase of TECC. Regardless of the triage technique (e.g., START, SMART, and SALT), certain universal principles apply in ASE. First, security is paramount. First responders are frequent targets in AS/MCI internationally and increasingly within the United States. Armed LEO should tightly control access to the triage site and triage personnel. All casualties, victims, and bystanders should be searched for weapons or explosive devices prior to being allowed into the triage area. Crowd control is essential and, if absent, can impede proper triage, patient stabilization, and evacuation. Second, conventional MCI-triage tools may initially categorize torso gunshot victims as “green” because they can ambulate. Frequent reassessment is critical, and MCI-triage tools should never trump common-sense clinical decision making. Finally, as triage may occur at several casualty collection points (CCP), communication is paramount for proper patient tracking and resource allocation.

Evacuation is a tiered process in ASE response. Rapid extraction from the direct-threat zone and expeditious transportation to definitive care is critical for casualty survival in AS/MCI. Evacuation includes movement from point of injury to a casualty collection point or evacuation platform (e.g., ambulance or patrol car) and transportation to first-receiving facility. First responders should be trained on proper operational-rescue and casualty-movement techniques. In general, EMS/Fire should initiate damage-control resuscitation (DCR) strategies during transport, which include mechanical hemorrhage control, normotensive or hypotensive resuscitation, hypothermia prevention, and other conventional advanced trauma life support (ATLS) interventions. EMS providers should limit time on scene and, as possible, conduct interventions during transport.

Use of unconventional, nonmedical transport may have a role as an alternate or contingency evacuation platform in AS/MCI. In the initial 30 minutes after the 2012 Century Theater shooting, LE transported 75% (18/24) of the victims to first-receiving facilities with 100% survival. Data from Philadelphia also support selective LE transport with shortened transport times and improved survival for urban gunshot and stabbing victims. Local leaders should determine, via an HVA and gap analysis, whether LE officers and patrol car-based casualty transport will be the primary, alternate, contingency, or emergency (PACE) evacuation platform.

Hospital

Hospitals and health care systems should immediately activate their Hospital Incident Command Center (HICC) on notification of a community AS/MCI. All area hospitals, not just the primary receiving facility, should immediately increase their security posture if there is an AS/MCI in their community. Hospitals are considered a soft target by perpetrators and are known to be a critical component of community response to AS/MCI. Security should initiate controlled-access procedures, assist with searching and clearing of victims, coordinate with local LEO, and provide heightened presence at points of entry to the facility. The public information officer (PIO) should be engaged early in the process and should have experience with handling LE investigations. There will be a huge demand for information. Medical staff should be instructed to follow proper communication procedures, refrain from any use of social medial platforms, and rigorously abide by HIPAA regulations. The PIO should ensure that communication requests do not interfere with providers’ ability to care for patients. Communication protocols should plan for loss of cellular phone communication.

AS/MCI events result in a predominance of high-acuity penetrating trauma with overwhelming onsite mortality. Victims may present with orthopedic injuries sustained while fleeing, cardiopulmonary complaints, and severe stress reactions as seen after the 2013 Washington, DC, Navy Yard Shooting (personal communication with hospital and first responders). MCI protocols should be activated, emergency departments cleared, and operating theaters prepped. Note that standard MCI discharge policies may need revision; regardless of complaint, patients may have some reluctance to leave the emergency department (ED) in the aftermath of an ongoing AS/MCI. Research on postbombing events demonstrates a multiple-surge phenomenon where high volumes of low-acuity patients self-present early to local hospitals, overwhelming resources. There are no data to support this observation in AS/MCI. More recent information from the terrorist attacks in Aurora and Boston suggest that in AS/MCI, the first-receiving facility should be prepared for a continuous surge of mixed-acuity patients.

Immediate resuscitative care should focus on DCR, mechanical hemorrhage control, balanced blood-product administration for those with hemorrhagic shock, tranexamic acid per protocols, and early operative intervention as needed. Early communication with ancillary services such as the blood bank, patient transportation, and radiology is critical, especially in the setting of restricted access activation. Although infrequent domestically, the concurrent use of IEDs in ASE is increasing globally and should prompt first-receiving facilities to plan for multiple, highly complex-trauma patients.

AS/MCI events frequently occur in small to mid-sized communities and affect people with little exposure to violence. Beyond victims and their families, the psychological toll on first responders, medical providers, and staff can be immense. It is critical that hospitals integrate staff debriefings and early mental health counseling into their response plans.