School Shootings: School Shootings: An EMS An EMS

PerspectivePerspectiveClifford Neal, D.O., FACEP, FACOPClifford Neal, D.O., FACEP, FACOP

Regional EMS Medical Director Seven Mountains EMS CouncilRegional EMS Medical Director Seven Mountains EMS Council

Tactical EMS Physician Centre Lifelink EMSTactical EMS Physician Centre Lifelink EMS

DisclaimerDisclaimer

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

Objectives:Objectives:

• Better understand the history of school Better understand the history of school shootings shootings

• Understand the motivation, similarities, or Understand the motivation, similarities, or lack thereof regarding school shootingslack thereof regarding school shootings

• Improve understanding of the planning, Improve understanding of the planning, training, and equipment required to training, and equipment required to manage this type of eventmanage this type of event

• Understand the most efficient EMS Understand the most efficient EMS response for the event and for the fallout response for the event and for the fallout that ensuesthat ensues

What would you do?What would you do?• Warm, sunny day in MayWarm, sunny day in May• A disturbed male A disturbed male

student has just opened student has just opened fire with an fire with an semiautomatic rifle. semiautomatic rifle. First shots occurred in First shots occurred in an auditorium during a an auditorium during a rally, he is currently rally, he is currently walking classroom to walking classroom to class room.class room.

• The radio is active with The radio is active with multiple police, fire and multiple police, fire and rescue responsesrescue responses

• Active shooting is on-Active shooting is on-going, and the number going, and the number of shooters is uncertain.of shooters is uncertain.

The Problem: Looking at The Problem: Looking at the past decadethe past decade

• > 387 school > 387 school shootings since shootings since 19921992

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

The ProblemThe Problem

• School shootings School shootings have resulted in have resulted in over 50 deaths over 50 deaths since 2012.since 2012.

• Majority of states Majority of states have now have now experienced at experienced at least one school least one school shootingshooting

Are deaths due to school Are deaths due to school shootings on the rise?shootings on the rise?

Total ShootingsTotal Shootings

Fatalities Fatalities

Who dies in school Who dies in school shootings?shootings?

The ProblemThe ProblemOnce the shooting starts….Once the shooting starts….

• On the average, On the average, someone shot every someone shot every 15 seconds15 seconds

• Average incident last Average incident last 12 minutes, 37% last 12 minutes, 37% last less than 5 minutes*less than 5 minutes*

• 43% the event is 43% the event is over before law over before law enforcement arrives*enforcement arrives*

*FBI law enforcement bulletin May 2013*FBI law enforcement bulletin May 2013

The Start????The Start????Columbine High SchoolColumbine High School

April 20, 1999April 20, 1999

Greencastle, Greencastle, PA 1764PA 1764

4 Lenape Indians 4 Lenape Indians attack the Pontiacs attack the Pontiacs Rebellion SchoolRebellion School

July 26, 1764July 26, 1764

Schoolmaster Enoch Schoolmaster Enoch Brown and 11 Brown and 11 students killedstudents killed

Other School Other School Shootings in PAShootings in PA

Sept 17, 1996 Penn Sept 17, 1996 Penn State UniversityState University

Jan 7, 2006 Bishop-Jan 7, 2006 Bishop-Neuman Js/Sr High Neuman Js/Sr High School WilliamsportSchool Williamsport

Oct 2, 2006 West Oct 2, 2006 West Nickel Mines Amish Nickel Mines Amish SchoolSchool

Nov 13, 2013 Nov 13, 2013 Brashear High Brashear High School., PittsburghSchool., Pittsburgh

Who could do this kind Who could do this kind of thing?of thing?

WRONG ImpressionsWRONG Impressions

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

The Shooter: The Truth The Shooter: The Truth by Generalityby Generality

• No clear cut No clear cut stereotypestereotype

• Variable motivesVariable motives• Single vs. Multiple Single vs. Multiple

ShootersShooters

The Shooter: The Truth The Shooter: The Truth by Statisticsby Statistics

• Is often single Is often single gunmangunman

• Statistically uses Statistically uses small armssmall arms

• Is Male 97% of the Is Male 97% of the timetime

• Has a history of Has a history of mental illnessmental illness

• May be a current or May be a current or former student(s) at former student(s) at the targeted schoolthe targeted school

The Shooter: The TruthThe Shooter: The Truth

• Attackers make plansAttackers make plans• Attackers talk about Attackers talk about

their planstheir plans• Attackers are often Attackers are often

encouraged by othersencouraged by others• Attacker has chosen Attacker has chosen

one or more targetsone or more targets• School staff are often School staff are often

the first respondersthe first respondersPreventing School Shootings: A Summary of a Preventing School Shootings: A Summary of a

U.S. SecretU.S. Secret Service Safe School Initiative Service Safe School Initiative Report 2002Report 2002

The EventThe Event

• Short lived Short lived (shooting typically (shooting typically over in 12 minutes over in 12 minutes or less)or less)

• Confusion delaying Confusion delaying 911 calls911 calls

• Response of policeResponse of police• Response of the Response of the

School StaffSchool Staff

The Role of EMS in School The Role of EMS in School ShootingsShootings

• Lessons learned Lessons learned from military and from military and civilian eventscivilian events

• Interagency Interagency planning and planning and cooperationcooperation

• Preparation is Preparation is paramount paramount

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

FranklinFranklin

PreplanningPreplanning

• Multidepartmental : Police, Fire, Multidepartmental : Police, Fire, EMS, Federal and State AgenciesEMS, Federal and State Agencies

• Develop SOPs for responseDevelop SOPs for response• Real time communication between Real time communication between

communications center and communications center and emergency personnelemergency personnel

• Safety EquipmentSafety Equipment

Planning is Planning is NOTNOT training training

TrainingTraining

• NIMSNIMS• OPSECOPSEC• Multiple Staging Multiple Staging

OptionsOptions• Check for “dead Check for “dead

zones” with radio zones” with radio communicationscommunications

• Real Response TimesReal Response Times• Access to the Access to the

buildingbuilding

Staging: Are You The Staging: Are You The Secondary Target?Secondary Target?

• Vary Staging Sites Vary Staging Sites with Trainingwith Training

• Screen Area For Screen Area For Obvious DangersObvious Dangers

• On Site SecurityOn Site Security

So Here You Are……So Here You Are……

Your Response Must Be Your Response Must Be Swift and IntentionalSwift and Intentional

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

Safety Zones: An Safety Zones: An Introduction to TacticsIntroduction to Tactics

• Hot ZoneHot Zone• Warm ZoneWarm Zone• Cold ZoneCold Zone• Hot zone may varyHot zone may vary

As The Cavalry ArrivesAs The Cavalry Arrives

• Multiple VehiclesMultiple Vehicles• Multiple WeaponsMultiple Weapons• Lots of AdrenalineLots of Adrenaline• Establish unified Establish unified

Incident CommandIncident Command• Establish Establish

PerimetersPerimeters

So Does Everyone Else…So Does Everyone Else…

• ParentsParents• The PressThe Press• Walking woundedWalking wounded• VIPs?VIPs?

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

School Shootings: MCI School Shootings: MCI With A TwistWith A Twist

• Everyone is a Everyone is a potential shooter potential shooter until patted down until patted down and clearedand cleared

• Rapid TriageRapid Triage• Establish safe area Establish safe area

for triage and for triage and treatmenttreatment

• Shooting may still Shooting may still be activebe active

EMS Response: Who EMS Response: Who should be first up?should be first up?

Primary EMS Primary EMS Response:Tactical EMS?Response:Tactical EMS?

• Knowledge of Knowledge of TacticsTactics

• Ballistic ProtectionBallistic Protection• Role of “Front Line Role of “Front Line

Triage”Triage”• Response timeResponse time• Dedicated to their Dedicated to their

SWAT teamSWAT team

TTactical actical EEmergency mergency CCasualty asualty CCare: Merging are: Merging

FunctionsFunctions

• Additional Additional training for non-training for non-tactical EMS tactical EMS providersproviders

• Protective Protective equipmentequipment

• Beyond the Beyond the concept of staging concept of staging in the cold zonein the cold zone

Why Why T.E.C.C.?T.E.C.C.?

While EMS is staged, While EMS is staged, someone is shot someone is shot every 15 secondsevery 15 seconds

Entry in to the warm Entry in to the warm zone may change the zone may change the outcome of this outcome of this tragedytragedy

Endorsed by FEMA, Endorsed by FEMA, United States Fire United States Fire Administration and Administration and the IAFFthe IAFF

The Hartford The Hartford Consensus : THREATConsensus : THREAT

• TThreat suppressionhreat suppression• HHemorrhage emorrhage

controlcontrol• RRapid apid EExtraction xtraction

to safetyto safety• AAssessment by ssessment by

medical providersmedical providers• TTransport to ransport to

definitive caredefinitive care

Protective EquipmentProtective Equipment

• Clearly marked Clearly marked clothing clothing identifying EMSidentifying EMS

• Minimal vest /shirt Minimal vest /shirt with highly visible with highly visible markingsmarkings

• Body Armor for Body Armor for anyone responding anyone responding in to the warm or in to the warm or hot zoneshot zones

Advance TriageAdvance Triage

• Rapidly performed in Rapidly performed in the warm zonethe warm zone

• Direct walking Direct walking wounded to a specific wounded to a specific exit with hands up and exit with hands up and exposedexposed

• Communication with Communication with who will be exitingwho will be exiting

• Notify Triage Officer of Notify Triage Officer of impending litter casesimpending litter cases

• Establishing a CCP?Establishing a CCP?

CCasualty asualty CCollection ollection PPointoint

• CCP may vary by CCP may vary by incident or timeincident or time

• Warm zone with Warm zone with relative safetyrelative safety

• Should be to the Should be to the rear of the event, rear of the event, with armed with armed coveragecoverage

• Access to means of Access to means of rapid egressrapid egress

Entry and Egress: Entry and Egress: Secondary DevicesSecondary Devices

• Booby trapsBooby traps• Secondary Secondary

ShootersShooters• Pre-planned Pre-planned

Secondary TargetsSecondary Targets

Evidence PreservationEvidence Preservation• Avoid smudging Avoid smudging

footprints, blood footprints, blood smears/spatterssmears/spatters

• Avoid contact with Avoid contact with weapons, spent weapons, spent roundsrounds

• Use of paper Use of paper rather than plastic rather than plastic bags.bags.

• Hands/WoundsHands/Wounds

Treating the physically Treating the physically wounded: EMS care in wounded: EMS care in

the cold zonethe cold zone• Triage tag useTriage tag use• Similar to other MCIsSimilar to other MCIs• Initial care in the Initial care in the

treatment areatreatment area

MMassive hemorrhageassive hemorrhage

AAirwayirway

RRespirationespiration

CCirculatoryirculatory

HHypothermia, Head ypothermia, Head

InjuryInjury

Typical InjuriesTypical Injuries

• Firearm related Firearm related woundswounds

• Blast InjuriesBlast Injuries• FallsFalls• BurnsBurns

Treating the VictimsTreating the Victims

• Physical InjuryPhysical Injury• Psychological Psychological

InjuryInjury• Family and FriendsFamily and Friends

The Lasting The Lasting Impressions…Impressions…

• Extends well beyond Extends well beyond physical injuryphysical injury

• Extends beyond those Extends beyond those in direct contact with in direct contact with the shooterthe shooter

• Increase in Increase in depression, suicide, depression, suicide, anxiety, fear.anxiety, fear.

• Experiences of EMS Experiences of EMS providersproviders

• CISMCISM

In ReviewIn Review

• School shootings are becoming more School shootings are becoming more commonplace, fatalities are notcommonplace, fatalities are not

• The changing response of EMS: TECCThe changing response of EMS: TECC• Who becomes a “victim” of the event Who becomes a “victim” of the event

may extend well beyond direct contactsmay extend well beyond direct contacts• After MANY debriefings for mass After MANY debriefings for mass

shootings, the recurrent key is shootings, the recurrent key is PRE-PRE-PLANNINGPLANNING and and MULTI-MULTI-DEPARTMENTAL TRAININGDEPARTMENTAL TRAINING

Questions?Questions?