“Send Them In”

By now, the New York Times article from last week has made its rounds in the EMS online community.  If you have not read it, I will give you the short version.  Based on the response to the Boston Marathon as well as some other high priority incidents, Federal Emergency Management Agency released new guidelines this past September in regards to the response of first responders to active shooter incidents.  The new recommendations revolve around what FEMA’s fire administrator Ernest Mitchell Jr refers to as “risk a little to save a little, risk a lot to save a lot.”  According to FEMA, risking a lot means sending EMS responders into the “warm zone” of an incident to treat and extricate patients.

Most of the article revolves around one particular paragraph of the seventeen page document:

b. While the community-accepted practice has been staging assets at a safe distance (usually out of line-of-sight) until a perimeter is established and all threats are neutralized, considerations should be made for more aggressive EMS operations in areas of higher but mitigated risk to ensure casualties can be rapidly retrieved, triaged, treated and evacuated. Rapid triage and treatment are critical to survival.

Rush in, keep your heads down, and get out safe.  They have not completely ignored our safety, however, adding a few lines later:

d. If exposed to gunfire, explosions or threats, withdraw to a safe area.

e. Consider/Investigate the use of apparatus’ solid parts such as motor, pump, water tank and wheels as cover in the hot zone. Understand the difference between cover (protection from direct fire) and concealment (protection from observation).

f. Remove victims from the danger zone in a manner consistent with predetermined agency training and standards of practice. LE officers may bypass casualties in order to eliminate the threat.

Recommendation “f” leaves me with some hope that there eventually will be more mandated training and education for EMS providers, but the document seems to largely ignore any mandation of this.  There are, however, recommendations made in regards to what FEMA feels should be addressed when planning, and developing standard operating procedures.  For example, much of the treatment modalities recommended revolve around tactical emergency casualty care or “TECC” which includes “hemorrhage control techniques, including use of tourniquets, pressure dressings, and hemostatic agents. Training must also include assessment, triage and transport of victims with lethal internal hemorrhage and torso trauma to definitive trauma care.”  Good start, but if you ask me there is a lot missing from this document.

First of all, in the overall “response” phase of the incident, why have there not been any communications mandate to develop common radio channels to be used by all responders in the case of these incidents to insure interoperability?  Messages can be lost when they are relayed from a field provider to a dispatcher to another dispatcher to a field provider, especially in a setting where the 9-1-1 lines will more than likely be ringing off the hook.  Responders need to be able to talk to each other and cut out the middle man, if you will.  For example, I was staging for a call just this past week waiting for law enforcement to secure the scene.  While monitoring the police frequency, we heard the request go through for EMS to enter the scene.  Since not all of the units in staging were listening to the same thing we were, we waited for word to be passed along.  It took easily thirty seconds to a minute for the message to get to us, and these are individuals who occupy the same room.  Sure, it’s a large room, but now add in telephone lines and call takers.  Safety messages take far too long to get to the people who need to hear them.  Interoperability has to be a mandate.  I cannot stress that enough.  No responder should have to walk around a scene carrying more than one portable to be able to talk to more than one involved agency.  And furthermore, every single responder should have a portable on their hip.  No exceptions.

For the first time in my career I am fortunate enough to work in a system that issues me body armor.  In twelve years as a paramedic in my last system, I spent time in some pretty volatile scenes.  While my policies call for me to wear my vest more often than I personally call for, being safer than I need to be is okay with me.  No where in this entire document is there any mention about EMS providers being issued body armor.  In fact, there is no discussion of body armor at all.  The expectation of FEMA is EMS providers will move into a warm zone with vested police officers at their side with nothing more than the shirts on their backs.  If anything, these incidents are the ones where vests are needed most.  This is not a shooting on a street corner which for the most part are “one and done” incidents.  These are people who want to run up body counts.  These are the calls where there are multiple explosive devices left to create as much chaos as possible.  Sure, there are take cover recommendations, but nothing at all having to do with body armor.  Some departments are doing it.  Just look at some of the scenes from the Boston Marathon bombings.  There were vested EMTs and paramedics there.  That should be the standard, not learning where the thicker parts of your ambulance are.

FEMA should take the initiative and make grants available to all communities to vest up their responders, and communities should be required to find the money to do it or access the grants.  If the recommendation is made that I put myself at a greater risk to be harmed, the recommendation should be made that I be protected more, and trained more.  The New York Times article goes on to quote Harold Schaitberger, IAFF president in Washington who says that “Trying to save victims in ‘warm zones,’ Mr. Schaitberger said, ‘is a different risk for firefighters, but not more of a risk than firefighters already take in responding into a burning structure.'”  Well, Mr. Schaitberger, not every EMS responder is a firefighter.  Increased risk needs to come with increased protection.  We should not put our butts in harm’s way just because we do in other aspects of the job.

Finally, what I find most alarming about the New York Times article is the focus on a single paragraph out of an entire document and how the public might perceive this.  Another one of these incidents is going to happen, and when the public and the media say, “they did not run in!  They did not do anything!”  It will be because they completely misunderstand the whole of what FEMA is recommending, as well as what FEMA is leaving out of the article.  Responder safety should be the more prevalent topic here.  The Times should be talking about what FEMA is doing to make these responses safe, not how they are pushing us to do more with what we already have.  But that will not sell papers, will it?  Once again, the media has failed us.  I would love to also blame our national EMS leadership, but for one, we lack unity.  Also, from what I have read on some List Servs, and learned from speaking to the likes of Brendan Morrison, creative editing for the sake of writing a “good story” is a far too frequently used tactic.

My hopes now is that services do the right thing.  FEMA has thrown down the gauntlet and given a recommendation that if you ask me is slightly narrow in its scope, but none the less it is there.  Now, it is time for career departments to step up, provide more training if needed, and start vesting up every first responder.  I know for a fact that I will hear from some people that their department has TECC trained providers, we do as well.  Some will say that their service has already given them a vest.  Still others will tell me that they took an active shooter class at the last conference they attended, and they feel ready.  The sad part is though, these statements will be the exception and not the rule.

There needs to be a balance of risk and safety.  We put ourselves at risk every day in EMS.  We step out on the side of busy roads.  We walk into unsafe scenes.  We are, however, asked and taught to be smart about it.  We are told to make smart decisions.  Without knowledge, those smart decisions cannot be made.  Give me the federally mandated training and give equipment that I need so that I can continue to make those smart, informed decisions.