Rescue Task Force: A Critical Appraisal

Over the past two decades, law enforcement and medical response to active violence has changed dramatically. Warm zone care is widely associated with the Rescue Task Force (RTF) concept, where medics triage and treat within the hostile perimeter in order to move care closer to the point of wounding. Despite significant efforts to implement these programs, there is a paucity of data looking at their effectiveness, as well as several high-profile failures of the concept. We will explore the origins of RTF; peruse the literature for evidence; and discuss the challenges of using warm zone care to reduce morbidity and mortality following these horrific events. Designed for physicians and others who provide medical oversight for prehospital personnel operating with tactical law enforcement teams who require a clearer understanding of Tactical and Law Enforcement Medical Professionals as part of their work.

Transcript

- Good evening. My name is Rick Murray. I'm the EMS director at ACEP. Welcome to our next in a series of section webinars.

- Awesome. All right, thank you very much, Rick. So, good evening everybody. Just quick introduction here. My name is Brian Springer. I'm at Wright State University in Dayton, Ohio. I've been full-time faculty here for the last 20 years. I direct our tactical medical division and have been a tactical medical provider working for multiple agencies now for, oh my goodness, also getting close to 20 years, thinking about, I'm about 18 at this point. I was part of a committee along with a number of other faculty residents, EMS personnel here in Dayton over 10 years ago. Our Mumbai committee that was formed through our Dayton area, MMRS, specifically to create a rescue task force program in response to any potential active shooter events that might come about was a big project, and it's been something obviously as a tactical medical provider that I've been very interested in studying as far as for what the best response is for a rescue task force. And we talk about rescue task force a lot. We hear about it a lot. But for those of us who are, you know, involved in this business, we also see that there've been a host of different issues and problems and concerns. What I wanted to do was to kind of just take a dive out there and see, when we're trying to study rescue task force and we're trying to figure out our response to active shooter hostile events, what are we actually basing this off of? What's the literature out there that's actually going and looking at, oh, hold on, let me see if my slides are going to advance. Ah, here we go. To actually to critically assess this and our response to mass casualty events. Obviously the focus is on rescue task force and to see what's out there and to see if we can do better, not just do better in terms of for the, you know, for rescue task force and for EMS response, but do better in terms of how to scientifically appraise what we're doing and see if it really is working and a way to consider other options or what has to change. So a little bit of background here. My guess is that most of you in the audience are already familiar with this, and by the way, let me just say right up front, this is pretty close to a lecture that I just gave last week in Indianapolis at FDIC. It was a little bit longer, I trimmed a couple of the slides, but this is still the basic content. And again, there, even though it was a lot of, you know, fire EMS instructors as opposed to physicians, a lot of people involved in emergency management who were there in the audience. Everybody I think is still fairly familiar with the background, but just we're just gonna touch on it for those who might not be. So active shooter response on the law enforcement side, really you can kind of look at this paradigm shift that occurred after the shooting at Columbine High School. I mean before that the response was form a perimeter around your hostile area, wait for SWAT to come in and take care of the problem and then move in. We realized, again, after Columbine that this was not an ideal model because the fact is that by forming a perimeter, all you're doing is just basically locking in this area where inside of that perimeter people are going to continue to be targeted and killed. And so the law enforcement response changed dramatically, which was no, we're not waiting for SWAT, we are going in, we are moving towards the sound of gunfire. And now there's been change even in terms of how that's worked from, you know, initially with whether it was, you know, diamond formation or spear or even individual officer response to active shooter events, which has been certainly successful several times out there during these type of events. But again, not to go into the details of that, but just to understand that there was this big change that came after Columbine. The EMS response, we can also go ahead and sort of look at things in terms of pre- and post-Columbine and EMS was, okay, we're, you know, standing by, basically, out here in the cold zone and we're waiting until law enforcement tells us it's all clear, whether that's patrol going in and saying it's all clear, whether it's SWAT knowing in and it's all clear, that's kind of how this is gonna work for us. And that really, that didn't change after Columbine. Okay, now we're not waiting for SWAT to say it's clear now we're waiting for whoever the initial responding officers are to say it's clear before we move in. At Virginia Tech, there was a kind of a look back after that to say, maybe we can do better with the EMS response. Getting to people sooner seems to benefit them. A couple of high profile instances in terms of both tactical medical providers as well as even individual law enforcement operators who are treating people close to the point of wounding. And that really sort of opened up some eyes on the EMS side. The Mumbai attacks in India certainly opened things up as well where here we basically had active shooter tactics being used as a full-blown terror event and the realization was that, yeah, we can't just be standing by till the situation is clear because this could be something that lasts for hours, days, we don't know. We have to be able to go ahead and start to respond inside of, at the very least get there in the warm zone. We need to go ahead and initiate care as close to the point of wounding and as soon after wounding as possible. So the rescue task force concept really had its origins basically in Arlington County Fire Department in Virginia back in 2009. And this was basically you had this integrated law enforcement EMS response, where you would go ahead and move your EMS personnel into the warm zone with armed security basically being provided by law enforcement, not to be part of the contact team, but to move in after the contact team and to start going in treating people inside of the warm zone. Again, get as close to the point of wounding as possible in terms of for treatment and to start initiating treatment as quick as possible as well as start to initiate evacuation. Some things that were really novel about this, especially if you look back to 2009, was providing your EMS personnel with ballistic PPE, and we're getting kind of used to this now seeing EMS and rescue where they're wearing body armor and wearing helmets. But back in 2009 you really didn't see that except on the tactical EMS side of things. And again, the concept at that time was really quite novel. Also, moving away from more traditional approach in terms of ABCs and typical protocols and initially using, taking from the military tactical combat casualty care where there had to be an understanding of tactical superiority, going and using your March algorithm as far as for dictating the care that was going to be administered and the general order that it was given in. And ultimately this evolved to TCCC as sort of the go-to first... Oh my goodness, as I'm having my little brain fart here. As being the initial means in terms of for going and doing that tactical triage and primary survey. So I took a look at tons of stuff. This is not the only literature search that I did. These were some of the keywords that I started going in Googling and looking on Google Scholar and looking at Medline and going through everything and of course from different articles and links that I found, I followed stuff and followed stuff and followed stuff, aside from of course going and looking at this phenomenon for many, many years just in my role as a emergency physician and as a tactical medical provider as well. And found some really interesting stuff, but also found that we really are lacking in terms of really good scientific literature looking at our response to this phenomena. Aside from going through all of those different searches and what I found, I went through different databases, different summary reports, from the database side of things, taking a look at FBI, Mother Jones, taking a look at the Violence Project and we'll talk about those a little bit later. Also, this is only a few of the names, really not representative of all the people who really have expertise in this topic, be it medical response, active shooter response who I have talked about this with or discussed it with, trained with, et cetera. Also, I have attended some really good after action reports out there, provided through Ohio Tactical Officers Association, National Tactical Officers Association, and even right here in Dayton through the DMMRS, we've had some great speakers talking about some pretty high profile events. So, the problem itself, if we go ahead and we're looking at what are the medical issues here going on as far as with these, you know, active shooter hostile event, we've got good literature on what we see as far as sort the wounding patterns. Some differences actually between some of the different studies though, looking at what the preventable causes of death are and trying to really look at it as a separate phenomenon, not making the assumption that it's gonna be exactly the same that we would see in the military environment or even the law enforcement environment as far as officer involved shootings. What do we see in an actual active shooter event? We can see different trends that are out there, which have, you can glean that from the media as well as from the after action reports. And just, there was a comment by Dr. Bradley earlier regarding the latest active shooter event that took place north of Dallas and that it really is now becoming a very inclusive club in terms of male, female, white, black, Hispanic, where everybody is going in and joining into this now. And so our old thoughts about what the profile of active shooter was has obviously changed significantly. Now there's a few issues with this here when we discussed just literature on the problem, there's obviously there's a big time lag. People go and they study the data, they get these things published and already several years will lapse before these articles get out there. I mean, you can see here obviously Reed Smith who did a number of these articles here, I mean brilliant guy, obviously very actively involved in looking at this study. But just even with some of these, just because of the time lag and how things change, again, we still tend to fall back on things like, hey, tourniquets are the magic talisman that's going to fix everything. Probably not enough emphasis on things like junctional hemorrhage. Certainly not enough in terms of trying to figure out a practical response to dealing with non-compressible torso hemorrhage, which is a big killer in these type of events. And we really don't have a good means of going and addressing that out in the field. And even though, of course, Mumbai was this big catalyst here in terms of for the formation of rescue task force, our system really still, and rescue task force itself is still designed around this kind of old school concept that you've got, you know, one or two shooters, they generally are not going to go mobile or attempt to escape. They are not going to engage law enforcement. And at the end of everything, they commit suicide. Yeah, we see these things in still some of the events, but things have changed dramatically. People trying to escape and successfully escaping, sometimes, engaging law enforcement, not committing suicide, will go and fight to the bitter end. So again, we have to try and catch up because this is an evolving threat. This is a really interesting paper here that was published in JAMA recently in their Network Open by Czaja, et al, looking at injury characteristics, outcomes and healthcare services use associated with non-fatal injuries sustained in mass shootings in the US 2012 to 2019. And they looked at 21 civilian public mass shootings. 15 of these they gleaned from public databases in six from media as well as from site investigators. And they use the congressional research service criteria as far as for an active shooter where it takes place in a public setting, you have civilians being injured indiscriminately by one or more firearms, the motive is not for criminal or other gain and they upped it here really to be 10 or more casualties for the events that they went ahead and looked at. They did some really good legwork on this. They contacted local trauma surgeons and emergency physicians and were able to get information on 13 shootings looked at, okay, there were 153 deaths that they studied, 887 with non-fatal injuries and they studied 364 of those non-fatal injuries in detail by talking with the people who actually were treating them. They found, indeed, that this problem where, again, we talk about how bad it is, but they pointed out just how terrible this is in terms of the burden that comes from these events. Not just the psychological burden, not just going and turning on the news and going, oh my god, again, but the actual true burden on the healthcare system in our society. They found in their study a very high number of wounded to deceased. And this was actually pretty interesting, 'cause if you look at older literature, if you go back 10 or 15 years and read about active shooter response, the stats really showed that ratio in general was low. Now, most of the time they were going and comparing that, let's say, to something military, where in the military you had a high number who were wounded, very few in terms of your casualties who would end up actually deceased and in active shooter events where it's basically somebody who's picking off vulnerable, soft targets at close range. You're going to see that that ratio is much, much, much smaller. But they found very high number who were actually wounded in these events. Injuries in terms of gunshot wounds, about two-thirds of them. But other problems too in terms of stampede injuries, all sorts of different orthopedic injuries from people trying to go ahead and flee and getting hurt. About one third required surgery and the morbidity of this was just terrible. The majority of people who ended up sustaining injuries, even these non-fatal injuries had some degree of long-term disability. A majority of them required readmission at some point for reassessment of their injuries. And the cost was tremendous in terms of... Now this was published back in just 2022, so just last year. But the best and most recent data that they could find, which is actually going back to about 2012 looked at the index cost for hospitalization for a gunshot wound and that was just about $60,000. So again, tremendous burden here in terms of, on our society and healthcare system. Now literature on the concept itself for rescue task force, most of it is really limited to descriptive stuff. Talking about the background, talking about concept origins and how rescue task force and this warm zone rescue is supposed to ideally work. And these are a couple of really good little background talks here as far as for the formation of the Arlington, Virginia Task Force. And once again, there's Dr. Smith talking about rescue task force and the concept in a presentation he gave to the National Fire Protection Association. And this is most of what you actually see. The Hartford Consensus, yeah, a lot of stuff that was published here talking about the adaptation of military lessons for civilian mass casualty events, multiple statements on there and the emphasis of course their acronym is THREAT, so threat suppression, hemorrhage control, rapid extrication to safety, assessment by medical providers, and then transport to definitive care. And their thought was that by going and training people at different levels, law enforcement, EMS and even civilians, we can build resiliency and enhance our medical response to these events. And here's some of the publications, I mean you can just basically, if you wanna look at all the different Hartford Consensus papers, just go ahead and Google it or put 'em in there to Google Scholar and you can go and read them in detail. As far as for the actual use of, you know, the initiation and integration of these concepts to actually use them, there are a couple articles that I found as far as for making these Hartford Consensus Medical School, a Hartford Consensus Compliant Elementary School. So you train up your teachers in terms of with Stop the Bleed, you have bleeding control kits, same thing basically with that medical school. Also some interesting survey data that they found, which was at least when responding to this survey that was put out there to civilians, that if you asked them, would you be willing to go ahead and accept some degree of personal risk to help others who are injured following something, again, high risk after a motor vehicle collision or some type of a shooting event, the majority of people said, yes, they would. Now, of course they're answering a survey and they probably don't wanna feel bad about themselves, so that's probably skewing it, but there were caveats, they said, yes, we'll do it, but we need the proper training and we need to have the equipment available. So interesting and maybe indeed a push towards, could there be utility to getting these bleeding control kits out there. So literature on execution, how well does rescue task force and warm zone care actually work, in terms of going and putting these programs together and trying to use them, a lot of descriptive stuff, talking about setting up programs, lots of surveys where we get attitudes as far as before and after people being trained up and your medics go, yeah, this is great, we're gung-ho about this. Doing post-training evaluations again. But generally pretty limited in timeframe. Actual detailed scientific examination of response is almost non-existent if you really are looking at peer-reviewed literature, there's stuff that's out there, several peer- and non-peer-reviewed data that look at some of the nuances of response, most of them looking at after action reports and databases, but there is not a robust collection of scientific assessment of rescue task force and what's working and what's not. So here's your typical sort of article in terms of for execution as far as we're actually putting together a rescue task force. It's not a bad article, this one here, from Bachman in 2019 where they talk about having this integrated law enforcement EMS rescue task force in a large metropolitan city. They, this was some interesting stuff here where they ran multiple scenarios throughout the city. They assessed the clinical care and said overall it seemed to be okay during these drills. And they said, we're gonna use these results to determine benchmarks and see if we can improve our performance. Okay, good for them, and now they need to see if they can improve performance and get that published as well. But whether or not it's gonna work in real life, we don't know. Here's another one, good example here, coming from Philadelphia. Philadelphia Fire and PD put together their rescue task force, what do they call their Rapid Assessment Medical Support. So their RAMS program. And they really did a pretty excellent summary in terms of talking about the needs, the problems that they encountered when they put this together, how they opted to go ahead and try and expand the mission in terms of for things like dealing with, you know, mass gatherings and whether or not they could go ahead and use these teams during them. And also some issues in terms of with mission creep, where some of the higher ups would say, hey, we wanna use you for A, B and C, where, no, that's not really what we're trained or equipped to do. The team itself has had multiple activations, but at least at the time of publication of this article, which is back in 2015, they said that they actually had not treated any major casualties in any sort of an actual type event. Now, after action reports, yes, they're very detailed and they are highly useful. Usually, if you go through them they'll point out highlights in terms of, okay, here's the things that went right, but all the good after action reports, really at the end there's a gap analysis in terms of here's what went wrong or here's what we could have done better. Kind of problem with this here is that there's little in the way of comparison in terms of with one after action report with other events. There also is little in terms of trying to interpolate their findings with what's already out there in the literature. Did the things that we found fit in with the findings of, you know, Dr. Smith and Dr. Czaja, et cetera, et cetera. And we don't see that. The after action reports tend to be very much, you know, silo bound and it's difficult to look at it and really interpolate in terms of how it fits into bigger picture. I mean some good ones out there, San Bernardino, the after action report really stands out in terms of their discussion about rescue task force and what happened, they were lucky from the standpoint of that SWAT was able to respond very, very quickly, because they were nearby and had been training at the time when the actual shootings went down. And so you had a SWAT medic who led the initial casualty care and triage and extraction of casualties to a CCP. It's sort of like what happened with Virginia Tech because of the shootings that took place earlier in the dormitory and concern that there was a killer at large before there was the actual mass shooting that took place, SWAT had already been activated, so they were able to respond very, very quickly and so you had tactical medics on scene very, very quickly. They discussed problems with radio incompatibility between law enforcement and Fire EMS. They were able to rapidly form a unified command, which was highly advantageous. And because of that, they concluded that they had very successful triage and treatment and evacuation that was done by San Bernardino's Fire Department. And all the patients who they transported survived. So they did well. They did activate rescue task force, rescue task force came from mutual aid from Rancho Cucamonga Fire Department and then they put together a second ad hoc rescue task force from other mutual aid companies. Now, what happened with those is during the shootout with the suspects, their force protection bail and went to go ahead and assist the officers who were involved in the shootout and left the sites without any force protection. Now, I get it in terms of going after these very highly armed and very dangerous individuals who were involved in a big gunfight here with SWAT, but they basically left everybody there just kind of hanging in the wind. And that is one of the key issues when you read about any rescue task force. The whole key is force protection, force protection, force protection. Now, yeah, we thought at that time, yeah, here's where the bad guys are, we're gonna go take care of it, you guys were fine. But you don't know, you don't know at that time for sure what the situation is. So there was certainly a failure here from the standpoint of force protection for rescue task force. Pulse Nightclub, their after action report, there was rapid treatment and transport by law enforcement. They used law enforcement vehicles, they used private vehicles to get people evacuated very, very quickly. Now during the first hour, this was a very dynamic situation here. This is your prime example of hybrid targeted violence, which started off initially as an active shooter event, then devolved into what became a hostage and barricade. And so things moved ahead at a very, very quick pace, and to their credit, the SWAT commander on scene who really led an excellent response, led it from inside of the nightclub... But because of this, there was no command outside to coordinate the response or stage additional resources as they arrived. Now most of us probably know about this as well during the Pulse Nightclub shootings that a block away, we had an Orlando Fire Department station, Station 5, and they remained locked down under the command of the on-duty battalion chief. There were actually still now responders at independent OFD command post that was located several blocks away. They began to designate roles and responsibilities for themselves and started going and basically putting together their own incident command. But there was no unified command. The communication was poor between law enforcement and fire, which ultimately ended up leaving EMS to say, no, we're not coming out. Now, two medics did go ahead and say, screw this, we're not staying in here, we're gonna go ahead and assist. And they went out there and they assisted in the rescue of something along the lines of 13 individuals something. And they did really, really good work at great personal risk as well. Once unified command was established, Orlando Fire began to assist with triage and transport and was successfully able to go ahead and help with this incident. Now, this is anecdote here coming from discussion from the commanders of the Orlando PD and Orange County squad commanders, who a couple of years ago were at the Ohio Tactical Officers Association's Annual Conference and did an after action report on the shooting. And I asked them, I said, so, you know, tell me about the EMS response. And the Orlando SWAT commander was pissed, I mean he basically just began cussing up a storm. If you all think I drop a lot of F bombs, you should have heard this guy talking about Fire and EMS and those issues with Station 5. Says he, you know, specifically requested aid, directly contacted, he said he sent officers over there to go ahead and basically bang on those doors saying, "We need your assistance, we need your assistance." When I asked him, I said, do you guys, you know, any thoughts about maybe trying to form rescue task force? And his response was, yeah, we have F-ing rescue task force. He said, just a month ago we trained with fire and we all checked off the boxes that we can go ahead and do this. But you know, when we asked for their help, they did not come out to help. Now again, mind you, guy was pretty angry. He also was occupied, obviously, during this event trying to go ahead and lead this very, very complex SWAT response. The Orange County Fire Chief Otto Drozd who, he's currently retired, but did talk about this also in an article discussing the problems with rescue task force, said yes, we had rescue task force trained responders, but trying to coordinate it all together was very difficult in this fog of war that was taking place. Said some of the rescue task force personnel who were arriving were mutual aid agencies. They had different levels of training. At the time when all of this was going on, nobody knew, was, you know, again, a terror event, hostage taking, what the heck is going on, the whole area basically was being deemed as a hot zone. And so they just did not feel that it was as safe for them to go ahead and enter into this scene. Comms were extremely complicated. Law enforcement and SWAT were using encrypted radios and again we had this lack of unified command. So lots and lots of problems. This wasn't just a matter of EMS saying no, we're not gonna go ahead and help. This is all the different problems that come up as far as with active shooter response and trying to use rescue task force. Databases. Databases out there. They're good from the standpoint of they provide a resource with which to go ahead and look at active shooter and active killer events. But problems with the databases, first off, are we collecting all of the information that we need? Many times we won't know until after the fact when we start to look at things and start to study events like, hey, we need this piece of information and we don't know if we're collecting it 'cause this is all still, grand scheme of things, relatively novel. The different databases that are out there do not communicate with each other. They're not always capturing the same information. And the databases may not communicate and oftentimes do not communicate with or match the findings of other different resources out there. So if you're using these databases and you wanna try and get more detail from NEMSIS or from the National Trauma Registry, sometimes you can't because they're speaking different languages. So here's a shout out to Dr. Dominique Wong who is on this webinar, and two really bright medical students, and I'm not gonna go into too much detail because they actually gave this as a presentation at ACEP a year back during the tactical medical section. And you can find details of this on the members only website as well. But they took a look at databases and after action reports and looked at the medical response in two active shooter scenarios. And, first off, just they went through some of the databases that they looked at, which were Mother Jones Violence Report and the FBI database. And so they found, again, varying definitions. So Mother Jones calling it indiscriminate rampages in public places resulting in four or more victims and then excluding shooting stemming from conventionally motivated crimes. The violence project uses that congressional research service definition where they again say four or more victims murdered with firearms, not including defenders being killed within one event. And then talking about in public location or locations in close geographic proximity. The FBI active shooter database, so defines active shooter as one or more individuals actively engaged in killing or attempting to kill people in a populated area. They talk about here, implicit in this is that they're using one or more firearms, and they actually talk a little bit about the active aspect, which implies that law enforcement and citizens have the potential to affect the outcome of the event based on their responses, that it's active, that it's occurring, that it is dynamic. They do not define a specific number of fatalities or casualties. And so their information database includes cases which have less than four fatalities. Now what did they actually do in terms of with this data? And again, I'm not gonna go through these in detail, you can find these on the members only website. But what they did was they put a timeline in terms of actual contact for care, looking at time in terms of medical contact secondary to law enforcement versus EMS. And they did that for both these shootings in terms of the Aurora Century theater shooting as well as the Marjory Stoneman Douglas High School shooting in Parkland, Florida. And what did they find? They found that in both events, law enforcement provided the fastest care and cared for the majority of critical casualties. In both events, your traditional and your innovative EMS access to patients was delayed, delayed significantly, compared to law enforcement, which demonstrates the importance of training and equipping law enforcement and medical skills and mass casualty training, yes, and also the importance of unified command and inter-agency training in order to go ahead and get care as close to point of wounding as possible. Jim Etzin, who's a EMS guru, who also goes and runs the annual Active Assailant Conference up in the Detroit area in Michigan. It's the beginning of June. He always has some really good after action reports there as well. So something that if you're in the region and able to go ahead and attend his conference, I would recommend it strongly. He gave a webinar with the National Tactical Officers Association last year, and he called it Rescue Task Force: Public Safety's Current Jedi Mind Trick. And this was really cool what he did, he looked at nine mass shooting incidents from 1999 to 2016, basically kind of starting with Columbine and going through Pulse Nightclub. And I called Jim when I looked at this data and I said, dude, why isn't this published out there? Why is this not something that's actually out there in the scientific literature? And he said that his first post-retirement project, 'cause he's planning on retiring here in probably about the next year, he says he's gonna update this data and he is gonna work on publishing it. So I got him to swear to it there. So again, look at these nine mass shooting incidents from '99 to 2016. Looked at 117 non-ambulatory casualties and found that 86 of them, so 73% were extracted by law enforcement and 31, so 26%, extracted by fire EMS. So in these events, again, three quarters of the non-ambulatory casualties were actually extracted by law enforcement. Now if you wanna look at this differently here too, so again, in four of the nine incidents, so almost 50%, all the non-ambulatory casualties were removed by law enforcement and basically there's a fragility index to that. If it wasn't for one Virginia Tech casualty who was non-ambulatory and was removed by EMS, it would've been five out of the nine. So over half of these instances where all the non-ambulatory casualties actually ended up being removed, not by EMS but by law enforcement. And again, only 15%, two of these nine incidents where all of the casualties were removed by Fire EMS. So law enforcement getting to people quicker, the first ones oftentimes to be going and initiating care and many times being the ones who are going to be evacuating your non-ambulatory casualties. Forgive me for saying that. Not necessarily evacuating, certainly extracting or extricating them from their, many times though, evacuating them in terms of actually putting them in law enforcement vehicles and getting them to the hospital. Another really interesting study here, this was Klassen et al, including our section member Dr. Sztajnkrycer, as well, looking at EMS response to mass shootings and active shooter incidents in the US from 2014-2015. So just in one year describing injury patterns and EMS response and interventions to mass shooting and active shooter incidents. And they identified them through the FBI's database, and again, using their definitions and tried to match this up in terms of finding these active shooter incidents and then taking a look at NEMSIS and trying to find data on the casualties in the response through NEMSIS. They identified 608 mass shooting incidents of which 19 were classified as active shooter events. They were able to find NEMSIS data on 226 of the mass shooting incidents and a total of 5 of these 19 active shooter incidents. So we talked about issues with these databases, not only having issues communicating with other databases, in terms of active shooter databases, but problems communicating with other databases that we have that look at emergency medical response, in this case, NEMSIS. They found location of wounds included extremities, chest and head and neck. They were not terribly pleased by the number of tourniquets as tourniquet use is only documented in six of the victims total in the cases that they were reviewed. And this is also a little concerning as well. Dispatch complaint did not suggest that there was a shooting or some other potentially dangerous scene environment in 15.9% of the records. Now, obviously, again there's problems here, most likely with data being lost in terms of these issues with trying to identify the active shooter incidents, trying to find ones where they could go ahead and find NEMSIS data. So again, we are not in different databases always collecting the information that we need. There have been a number of notable communication failures in active shooter response. We've discussed some of them, but again, going through these, these are some of the better known right here. So Century Theater, there was ongoing issues in terms of with the communications as to whether or not the shooter was actually in custody. And it was extremely problematic getting EMS and fire to go ahead and respond. And ultimately what happened was law enforcement took it upon themselves to go ahead and evacuate most of the casualties. Now, problems occurred as well, issues in terms of communication, problems with lack of unified command, problems with staging being separate in terms of space that made communication and even basically getting into casualties and then successful egress problematic as well. So that was one of the really first big kind of bungles that we looked at and said, oh man, we gotta do a little bit better here. The Pulse Nightclub, we discussed the communications issues that occurred there, and again, I do want to emphasize the fact that two medics went ahead and really took great personal and professional risk to go ahead and to assist. And again, a big part of the problem there wasn't just that EMS was basically cowering behind their walls. The big problem again was communication, communication, communication. And once there was unified command, things were able to go ahead and to move ahead as far as for actual casualty response and evacuation. Stoneman Douglas High School, Parkland, Florida, this one's kind of unique from the standpoint of that rescue task force was stymied not on the part of EMS, but by law enforcement. Deputy fire chief at the scene asked somewhere along the lines of six times to deploy rescue task force to assist and was denied each time by a completely overwhelmed and indecisive incident commander, and again, incident commander, law enforcement incident commander. What you need to have is unified command so that you've got instant command from law enforcement and EMS working hand in hand. They did not. And again, here is a case where we had fire EMS saying, we got rescue task force let us in. And law enforcement said no, we we're not sure what's going on here. The Oregon District right here in Dayton, Ohio, a couple of years back, problematic. The shooting itself was over in about 30 seconds. Guy was put down very, very quickly and effectively by responding law enforcement, but not before he killed nine people. Dayton Fire responded. And again, this is the same Dayton Fire where myself and others really put a lot of work and effort into creating our rescue task force program to be able to get warm zone care and Fire EMS staged, and when law enforcement was, an incident, once again, incident command, not unified command, incident command on law enforcement side saying come on in and assist, there was a lot of scuttlebutt going around, a lot of radio traffic and discussion about at the possibility of a second shooter who was driving around in like a Chevy Suburban or something along those lines. And so it was just not clear that this was now, again, that the shooter was down at the area was secure, at least warm zone secure. And so significant delays, which ultimately led to, again, law enforcement taking the initiative in terms of treatment and ultimately not just extraction to a CCP, but actually evacuation of the injured to local and regional hospitals. So what are the issues here, if we start going and digging through these findings in literature. Obviously some of this is a mindset problem, but I think that we can fairly easily overcome that. It takes time, I think. There's still gonna be some people who are very set in their ways of thinking on the law enforcement and the Fire EMS side, but eventually they go away. Well, sometimes they end up in command positions first and that can be a problem. But, you know, the I like to use the burning building analogy where if we look at rescue task force failures and people say, well, you know, when the balloon goes up, you know, fire EMS isn't really gonna go ahead and respond, and the firefighters will go and run into a burning structure to go ahead and to rescue people in there. They will put themselves at significant risk, put their lives at risk, risk being killed, being burned, being maimed to go ahead and to save others. But that's also what they are trained for and what they are equipped for. It's in their mindset that this is something that we do and they know how to go ahead and do it. And so they accept that level of risk that goes with it. I think we can change the mindset in terms of on the EMS side that, hey, responding in a warm zone to these type of mass casualty events and active shooter events, this is part of what you do. And I, again, we're seeing that culture shift and we're seeing more medics out there, again with body armor and understanding that this is kind of part of what they're going to have to do. Same thing on the law enforcement side, where, you know, 15 years ago, most cops out there, they weren't carrying tourniquets, they were like, oh, you know, tactical 911 where they get the medics, you're calling dispatch and saying, hey, we need a medic, somebody's been shot, to now where they're actually going and even after an officer involved shooting, going and starting to render aid to casualties. Communication is huge, obviously, we need to be able to communicate better. There's problems obviously in terms of with encrypted radios and things like that. But the big thing really in terms of communication is we've gotta get communication working at the higher levels. So once again, unified command is so critically important. Now, fog of war and hot, warm and cold zone concepts... So I'm trying to remember now when the webinar was a year or maybe a little over a year ago when we had Dr. Alex Eastman on here talking about the Dallas Fire Department and talking about some of the issues in terms of with the 2016 shootings, which were five Dallas PD officers were killed. But question came up to Dr. Eastman about rescue task force and he just kinda rolled his eyes and basically said, and I've actually seen him quoted on this elsewhere other than that webinar, he's like, you know, rescue task force looks good on paper until you actually try to use it. And he's like, it just doesn't work in the fog of war. And it basically said that these concepts in terms of hot and warm and cold zone or your phases of care, that they're after action concepts. That trying to figure it out in the midst of a dynamic event just doesn't work. Now, I don't really fully believe that. I think that it can be very, very difficult in dynamic circumstances, but it can be done. I think we do it successfully in terms of for military medicine, I think we do it successfully as far as with tactical EMS and using SWAT medics out there and tactical medical providers. And so there's no reason why we can't figure out how to get better at delineating those zones of care or those phases of care during dynamic events, during ASHER type of events, active shooter and hostile events. Also still, I mentioned this earlier, problems here still evolving threats. The old where you're trained to fight the last war instead of the next. And if you look at just the, how it looks on paper, the hardcore set in stone rescue task force may or may not be the type of response that we need for these evolving and dynamic active shooter type of events. So, what are some of the solutions out there? You know, do we redefine medical providers? And by the way, I am itching to talk to Dr. Cayman 'cause he had talked about this and getting a grant. I don't know, maybe somebody who's tuned in today knows sort of what came about with this. Looking at first arriving responder training versus first responder on scene training. What's it better to do? Do we need to really go ahead and be investing our resources into creating these sort of specialized EMS sort of responses or do we need to do better in terms of training up, you know, law enforcement, do we need to train civilians more, again, do we fall back on things like, you know, stop the bleed and stuff, stuff that we've talked about in the Hartford Consensus. And so I'm not quite sure what he's come up with this, what he's come up with at this point on this. I did email him about it and heard back, but we have not yet had a chance to chat. But obviously looking closely at this. We need to certainly do more combined training for law enforcement and EMS. It has to be something that's done regularly. It can't just be a, yep, we've done it and check off the box. It has to become routine. We have to enhance our comms. Those have to be better. We have to emphasize unified command. And maybe just as it sort of stands on paper right now, the concept of rescue task force is kind of out to date. Maybe we need more, again, expanding this to other types of different warm zone care. I've saw just recently actually Dr. Wipfler sent me an article, somebody talking about Rescue Strike Force, which basically is using the concept in terms of having these protected or safety corridors where you create this sort of secure warm zone where you've got your law enforcement personnel stationed and it's the EMS personnel, your rescue task force types who go mobile, moving within that safety corridor, within that protected corridor to go ahead and start engaging in point of care treatment, excuse me, point of wounding care and treatment, extraction to CCPs, et cetera, to get people out of there in a quicker and more organized fashion as opposed to having these little individual teams with your medics and then your force protection moving with them. I don't know, I'm not sure how well that idea is gonna work in terms of reality. Seems conceptually to be okay. We actually rolled it out here and have been practicing with it here in the Dayton area, but we have not had a chance to actually go ahead and use it. This was, I thought, a pretty cool article here too. Again, an opinion piece that was in Police1 back in August of 2018, so several years old. But I think that the statements and conclusions of this author are spot on. Basically says that really to fix rescue task force, it's a leadership problem. It is a leadership problem. This is all relatively new stuff. Yeah, we've been doing it for a while, but in the grand scheme of things, this is all relatively new. Understandably, team composition and the training needs and equipment and tactics, all that require attention and effort. Clearly the author acknowledges that. So sure, establish your doctrine and figure all that stuff out. Then from there, the people who need to be trained up on this before you even go ahead and start equipping people and training them how to go ahead and function with rescue task force is your command staff. This has to be fixed at the higher levels in terms of both law enforcement as well as Fire EMS, and how are you going to more effectively go ahead and create unified command to enhance communications in these type of events? Train your command staff. Train them as individuals, Fire EMS and law enforcement, and train them together. Get those people all on the same page. Then, once you've got them effectively working together on this, that's when you can go ahead and actually start to train your personnel. And I'll just kind of end this here just anecdotally here, talking about our time course here in Dayton, Ohio. Again, the MMRS and the Mumbai Committee started working on rescue task force back in 2013, '14, actually even working on it, even before that. Before the Oregon District shooting, we were trying to get the mindset there in terms of going and using these sort of tactics and techniques by using them in novel uses, mass gatherings being probably one of the main ones, where when we had big crowds and if somebody was injured in a crowd or something like that, being able to go ahead and basically move in rescue task force. So you had your medics who were there, they had their law enforcement force protection, move them through the crowd and go ahead and get to the casualty. And that seemed to work pretty good, but that's still because that was really being looked at as, you know, just a relatively minor modification of more typical EMS response, and balloon went up in the Oregon District and our rescue task force kind of belly flopped. Because of that we started, and this was done jointly, we talk about at the command level between the chiefs of Dayton Fire as well as police, which was to form a tactical EMS program. The idea being that if we started getting Dayton Fire medics out there working with law enforcement special operations, that we could start to get this ideal trickle down mindset that kind of normalized this concept of going and working with law enforcement in the warm zone. And our most recent combined law enforcement and EMS training exercises, rescue task force was just back earlier this year over at the Dayton Convention Center and we were training using the safety corridor concept. Again, I liked what I saw, whether or not it's actually going to work the next time we have an event, I really don't know. But even here in terms of with the mind shift in terms of medics, it's beginning to accept this concept and being able to get out there and do this, it's been 10 years, so this takes a lot of time and all you have to do is flick on the news to realize we don't have that much time. We need to study this phenomenon more, we need to figure out what is going to work, we need to figure out what's not working and throw it away and be able to go ahead and make sound decisions based on best evidence. And right now, our best evidence, we got some good stuff out there, but still overall it is lacking and we need to do more. And that is what I have got. And are there, I guess I can look over, I don't know if we've got in chat, questions on anything. In fact, actually here, let me escape from the shared screen. All right, so questions, concerns, death threats, anything, please, open forum here.

- [Dominique] Brian, do you think we have enough data? I mean, you gave some very compelling cases, but do you think overall we have enough data to make a call one way or the other on rescue task force or law enforcement?

- Oh, no, no. I, well, now I'm still, I'm still going to say at this point, no, I think we, let me rephrase my answer to you. I think we have enough data out there that if we try to keep working on integrating it, if we come up with hypotheses, if we look at the data that's out there, which is going to be extremely challenging because it's in all these different formats out there, that maybe, just maybe, there is enough out there to go ahead and answer questions and make change. But there's not enough people who are doing that and not to point fingers or fault in terms of doing that. Again, you or you are somebody who actually tried, it's very, very challenging to do just because of what we actually have out there in terms of the data. It's not so much we don't have a paucity of data. We have lots and lots of data, but it's not, it's unorganized. And so using it is extremely challenging. So I say, you know, go for it. We probably can't, maybe there is enough out there to make conclusions, but we've gotta then, you know, form hypotheses and look and try and test them with the data that we've got. Does that make sense?

- [Dominique] It does. We have a question from Jason Pickett first, and...

- That figures.

- And then Robert Margulies.

- Jerry, you got a question? I don't-

- There we are. Sorry. They had to let me unmute. Sorry about that. But hey, good to see your face, man.

- Thanks, brother.

- We've been, you know, here in Austin, we've been pre-deploying our rescue task force since the George Floyd riots that we've had. And we've made that regular practice now for Fridays and Saturday nights in our entertainment district as well as for civil disturbance and large events such as South by Southwest on Austin City limits, and our experience, unfortunately, we've not published anything and I know I'm worthless and weak because of that, but we have found that that is, that communication piece that you're talking about, that really helps because in a the RTF team or the counter assault strike team, which is three officers and a medic to go direct threat for a hot zone response, that you've got that team together on the, listening to the police channel so there's not that filter that has to go up through the communications center from the on-scene officers across to the EMS communications down to the EMS unit. So it just enables a lot more direct communication between them. So RTF facilitates very well that passage of information between those elements. We've had several cases where RTF has, that pre-deployment RTF has been on scene within 30 seconds, 60 seconds of injury and has been able to affect some good outcomes as a result. But someday we'll get to publishing it. So I agree. I think that there's a paucity of literature on this. I hope that all of us are thinking of getting this into the literature so we can evaluate best practices.

- Yeah, yeah. I mean, I'm thinking right there, really, one of the key points if you do go ahead and push anything out there as far as with that experience is by using RTF routinely, one of the biggest advantages is you guys have teased out how to do better with the communications issue. And that's huge. That's really huge right there. I know you all have been listening to me ramble for the last hour and I know it's exhausting. So... But come on, bring it on, somebody's gotta have something to say. You know, let me, maybe this will pique some kind of interested responses here. So when I gave this lecture out at FDICI and I said it was, you know, a combination we have, you know, just your kinda line, you know, fire, EMS types, a number of older, more experienced emergency response people who are just kind of up there in terms of, you know, higher, higher level stuff. When I looked at my evals for the presentation, and I'm used to, you know, when I go, especially if I talk with EMS or I talk with cops, you know, I'm dynamic, I try, you know, I talk their language and make things really neat and interesting and bring up cool facts. And most of the people really liked it. The emergency management people seemed to really, they like this presentation, said, this is really interesting stuff to kind of chew on, but I swear, I got savaged by a few people who were in there who were like, this is, you're not, you know, they said this wrong audience, you know, we're not doctors. Which maybe, I don't know, maybe this is a little over some of their heads, but also you're not telling us anything. You're not giving us useful information that we can go ahead and take back. And I was a little hurt, but I mean, I sort of get it, and to me, the whole point of all this is to look at all this stuff that's out there and say, look, we've got all these problems, but it's hard to make recommendations based on what we've got. So I'm just kind of throwing the stuff out there and hopefully piquing people's interests.

- And I see-

- From Dr. Margulies. And then there was two, there's a comment after that. Let's see...

- I see, I see a question here. Any thoughts on prevention? As far as for actual active shooter, you know, hostile event prevention? Oh, boy, I will tell you, that is an entirely different topic that taps into so much different types of stuff where you gotta start looking at issues in terms of behavioral, you have to start looking into questions in terms of legal, you have to start looking into issues in terms of access to firearms. You have to, I think, start looking into issues like social media, et cetera, et cetera. It's just, I mean, yeah, I have thoughts about active shooter prevention, but it's, again, we could talk for days about that. Other questions specific to this, to the rescue task force and EMS response.

- [Dominique] we had, Dr. Margulies had his hand up next, so if we wanna let him speak, and then there's some questions from Steve Patterson after that.

- Oh, sure.

- [Robert] Good evening. Thank you, Brian. As usual, a tour de force.

- Thank you.

- [Robert] As those who are familiar with me, know I'm not an academic, I'm a patrol cop and I appreciate all of the combined force type of work that you're looking at, but I still think that we really need to be getting into the academies, we need to be talking to the directors of our state academies. We need to be working at a level where we start our individual officers, many of whom are going to be not in big cities, many of whom are gonna be county deputies patrolling 25, 40 miles from the nearest potential EMS response, many of whom are gonna be alone and backup is gonna be questionable. And we need to be getting the medical and trauma training started earlier in our police careers. I go back with this, in 1992 and '93, I was the medical director for the Hartford Open, a fairly large mass gathering. And we used a military concept of advanced parties mobile carts. We set up golf carts with cots. We equipped our medics with stuff that you would use in a mass event, the fluids, you know, that kind of stuff, different than a trauma situation. In '94, '95, I started working with a local SWAT team. It was a combined SWAT team, and it went fine until one of the local sheriffs discovered that a civilian was working with the SWAT. Well, I had a special deputy designator from the county sheriff, but that wasn't good enough. And that's what led me to the academy and my own commission. And then that's what really got me into training officers for being the only responder, not necessarily the first responder. My pitch, as it has been in the past, is that the glamour stuff, the SWAT teams, the high tech equipment, very important. But if we don't get the individual officer who is the first one in, the first one who goes to a domestic, the first one who shows up at the vehicle crash on the highway, et cetera, et cetera, et cetera, we are not serving the rest of our population.

- No, this is-

- Thank you.

- I agree with you 100%. And again, I was really kind of throwing this out more, especially since I put this together, really more for the, on the EMS side of things initially. But yeah I'm a big believer in terms of training patrol officers to be able to respond, not just in terms of being able to care for themselves or for their partners if they're injured, but being able to care for others who they encounter, who have been injured, who are, have encountered medical emergencies, you know, on and on and on. And I'll just say, again, going back a number of years, and Dr. Pickett was part of this too here in Ohio where we created self aid buddy aid class that we taught out at the Ohio Peace Officers Training Academy. That ultimately became Critical Injury First Aid, which is now part of the basic peace officer curriculum that you get at the academies here and in the State of Ohio. So again, a really big believer in that. And of course, now I'm going to just a confession here. So now we've had this program out here for a number of years, and you know how much research I've done on it in terms of looking at its effect? None. So I'm guilty as well of this, but yes, I agree, sir. We need to be training on our officers better, for sure.

- This might tie in also with that comment about the rural/urban. So Steve Patterson says, great presentation, disparity in tactics is ever present as a concern in rescue task force formation. So how do we formulate a national process? We were able to do this in California, but it still seems fragmented and this seems especially prevalent in rural versus urban plans due to resource availability.

- Yeah, yeah. Absolutely. I mean, I don't know what else to say to your comments except, yes, you are correct. You know, one thing that I've noticed in, if I've basically kind of, you know, gone at it with people for, you know, discussing rescue task force, what works, what doesn't, you know, oh, it's good, it's not good, et cetera, is to pull back and say, hey, well, you know what, one size does not fit all. And some of that is going to be, yeah, tactics will affect things, urban, suburban, rural, what the resources are, what your law enforcement resources and EMS resources are, are going to make things drastically different in terms of what you can do in terms of for your response. And so, honestly, to answer, how do we go ahead and address that? Well, start looking at the data that's out there and try and come up and formulate answers. Some of those answers will hopefully work, some may not, but we need to look at the problem. And that's one of the questions that has to be asked as far as differing tactics, differing resources, how can we pull this together in terms of improving warm zone care?

- [Dominique] Yeah, I agree 100% that this is also something that isn't gonna have one single answer. It's not only gonna be rescue task force that responds, that it's gonna have to be multiple agencies trained to have some job overlap and to be able to step in and fill the gaps where the others have not. You know, even if there is a perfectly well-trained rescue task force, if they're not able to say that scene is not hot, then you're gonna have to rely on your law enforcement to step in and flow in there, and then hopefully they can flow back out when rescue task force can come in. And we have another question from Dr. Christianson.

- [Randolph] I raised, I was thinking about raising my hand, but I don't really have much yet to add to the conversation here. My thought was that, yes, the rescue task force has to be tailored to the situation in which you find it, and it's gonna vary a great deal, from the nature of the law enforcement problem, to the barricaded hostage sort of thing, or just people out in the woods running away from the police, shooting others while running away, it sounds like we need to focus on the fundamentals and then somehow tailor those, tailor the individual response to the fundamentals of getting the medical provider in there and getting protection and even mobility.

- Yeah, I agree. I think if we nail down fundamentals and figure out what those fundamentals really need to be and push those out there, that people will take it and ideally apply it in terms of a means that they can use. I mean, if you look, you know, good experienced medics, you know, out there in the field, you know, they come across something that's atypical or unusual, but they're good, they're experienced, they're able to improvise their, you know, I hate to use the old improvise, overcome, adapt, kind of thing, but that's what they do. Law enforcement out there, again, well-trained and experienced law enforcement, when they encounter some really, you know, seriously hot situation that's kind of out of the realm of what they normally would deal with, the good officers will be able to go ahead and make it work with the resources that they got. A good emergency physician when something comes in and somebody's crashing and burning and they're going to be able to go ahead and use the resources that they got to go ahead and try and pull the individual through. And so, I think that if we create this culture where it's assumed that EMS and law enforcement will be working as a team in these type of incidents that we can from there maybe figure out what's going to, again, work best overall, but then really tailor it to different situations and different environments and resources. Oh, Dr. Crates, I see one of my residents here has submitted a question. Let me just read this here out loud, and if I don't like the question that he asked, he's going to have to go back and be an intern again. So let's say, as we have previously talked, there needs to be call to action in order to create the data banks on these events that can give us better insight. Who or what is the right level to advocate this policy, national, state, federal, have we explored joint position statement with ACEP, TALUM, and invited other players? N2A, NAMSP, SOMAAM, IFFF, think of it metaphorically similar to the original accidental death and disability papers. Yeah, yeah. No, I agree. Heck, right now we're at that point where we're trying to reach out to all these different organizations and figure out just what sort of tactical law enforcement medicine needs to go ahead and look like. I think that if we, as, you know, individuals get out there and start looking at this more and start going in and working together and start getting some publications out there, I mean, if we're gonna do, if you wanna put together joint statements and actually have them be of value, it should be more than just expert opinion. This is me personally, right? I think this. I mean, expert opinion is important, but I'm still, I don't worship at the altar of evidence-based medicine. That's not what drives every single thing that I do. But I think to really create policy and content and techniques and things that are going to be of use, they should be based on more than just, you know, anecdote and personal opinion and should be based on real data. And again, it's a challenge to do. And we're taking our first baby steps. So my answer to you there, Dr. Crates is yeah, publish something, dammit, and that way you'll have met your academic requirement, the RRC will be happy, your program director will be happy, and you'll be contributing to this literature.

- [Dominique] That's an excellent point. Okay. So not yours, Dr. Springer, Dr. Crates'.

- I'm going to allow him to advance to his R3 year. That was a good question.

- [Dominique] Terrific. Steve Patterson has another question. The data you presented is compelling with regard to the prominence of law enforcement officer rescue interventions. The FDLEO model seems to be the most common iteration of the rescue task force. But based upon this data, do you suggest we devolve from fire department involvement in a warm zone?

- No. No, no. I'm not suggesting that, I'm suggesting we look at whether or not to do that. And like I said, Dr. Richard Cayman, I think has looked at this and I'm not quite sure what he's got out there in terms of for data, but no, I am not saying we need to necessarily shift away from EMS. I'm saying we need to look and see what works. I don't know, maybe ultimately the answer is going to be that, yeah, this has to be predominantly law enforcement driven. But when looking at incidents, once you get unified command, things seem to gel. And so, I don't know, my personal feeling is that we can make this, that we can make this work, that we have to work on both houses in terms of law enforcement and Fire EMS, but we also need to go ahead and have them working routinely together on this. I'm not ready to give up on the rescue task force concept yet.

- [Dominique] Right. And I think, like you pointed out, so the cases we presented, you presented were a small number of the many cases of active shooter, again, depending on your definition. So it's just a small sampling of them, but it was definitely eyeopening. And when you look at the actual problem, so you wanna get your most critical people within the first 15 minutes, you know, how often is law enforcement gonna be able to say, this is warm zone in the first 15 minutes? So you can certainly see a problem. It doesn't mean that, though that is, rescue task force is not part of the solution. I agree. Also, Steve Patterson says it would be very controversial direction to take to say that rescue task force is off the table. And I think we can keep both elements together to evolve together.

- I hope so.

- Yes. Okay. I think that's it. I don't think we have any more questions. No more raised hands.

- Cool. Let me just say thank you all very, very much. I appreciate your time. I appreciate the really excellent comments and questions. I guess let me turn this over now to, you know, Rick and Deanna and so we can, the final housekeeping details before we ultimately go ahead and get signed off. Cool. Thank you all very, very much and hope to see you all soon at our next webinar. Pleasure everybody. And spread the good word to anybody who didn't have a chance to sign in that once this gets posted up on the members only website to watch, and send me comments, please.