firefighters support foundation

Firefighters Support

FoundationRapid Response and Treatment

Model (R2TM) for Active Shooter Incidents

--------Operational Detail

v3.0

About FSF

The Firefighters Support Foundation is a 501c3 non-profit organization whose primary mission is to develop, produce and distribute training programs to firefighters and first responders. All of our programs are distributed free of charge.

2R2TM - Operational Detail

Permission

Permission is granted to reproduce or distribute this material so long as the

Firefighters Support Foundation is credited as the source


Accompanying Video

This PowerPoint presentation accompanies the video presentation of the same title.

This program is a follow-on program to our introductory program on the R2TM (Rapid Response & Treatment Model) active shooter response model, titled: Active Shooter: the Rapid Treatment Model (note the name change of the model). We encourage you to view the earlier program first because familiarity with the basic elements of the R2TM is assumed in this program.


Presenters

• Jeff Gurske is an Engineer and Acting Lieutenant in the Portland metro area. Jeff is a training contractor/consultant, contributing author and adjunct college instructor.

• Craig Allen is serves as Training Sergeant in the Portland metro area. Craig holds numerous instructor certifications in firearms, defensive tactics, less lethal weapons and other tactical subjects.


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• Lots of good work being done nationally• Still a long way to go• How do we integrate?• What impacts does this integration have

on training, protocol and sustainability?

Integration of Public Safety

Welcome

R2TM - Operational Detail

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• 2007 – 2013 Highest numbers of incidents• 2014 – On track for a record setting year

• Historically these events have taken > 12 min• 2010 - 2014 90% under 5 minutes • Rumors of a 2nd shooter usually high

Time & Intensity

What We Know


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• Public safety response not integrated• Condition of our SOPs or SOGs• Tradition and culture

Incident Friction


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The Principles•Hot Zone: Exclusion •Warm Zone: Reduction•Cold Zone: SupportThe Problem:•#1 most common A.A. item•Causes a progress friction point

– Fire/EMS is waiting for the “all clear”

Zone Response


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• Level I Trauma Hospital– 14 years: 1996-2009

• 19,167 cases• Blunt and penetrating trauma• Results found:

– Increased mortality rate with scene times ≥ 20 min

Trauma StudyOrange County, CA

McCoy CE, Menchine M, Sampson S, Anderson C, Kahn C. et al. Emergency medical services out-of-hospital scene and transport times and their association with mortality in

trauma patients to urban Level 1 trauma center. Ann Emerg Med. 2013 Feb;61(2):167-74R2TM - Operational Detail

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Data driven answers:1. Mitigate the threat / saving life on the front end2. The life-saving timeline continues3. Mitigate time loss / saving life on the back end 4. Meaningful integration has the best chance to

impact life-saving across the spectrum

Law Enforcement Goal


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Data driven answers:1. Access patient as quickly as possible2. Address critical-fixable injuries3. Get patient to definitive medical care ASAP

EMS Goal


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Engineer the Response

• You may be able to use your current resources to operate efficiently

• Do not be distracted by tactics– Tactics require a functional system to be effective

• Engineer your response to work– Embed a “Warm Zone”


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• Friction • Psychological • Physiological • Environmentally

• Uncertainty • Remedy

• Experience• Training

Nature of Conflict


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• A combined effort putting the caregiver at the patient’s side within minutes of wounding to maximize life saving– Agency expertise

– Clearly defined roles

– Familiarity

– Simplicity

– Unification of Command

Systemic Problem-Solving


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“Everything in war is simple, but the simplest thing is difficult.

The difficulties accumulate and end by producing a kind of

friction that is inconceivable unless one has experienced war.”

Carl Von Clausewitz

R2TM Response


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• 3 Tenets:1. Rapid LE response2. EMS securely introduced into a warm zone3. Rapid treatment and transport of the victims

• Keep closest to normal SOPs

R2TM Foundation


R2TM LE Overview

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Response• Rapid Response Tactics • Threat mitigation• Initiate Sergeant / Battalion Chief link-up

Assessment• Establish foothold (FOB)• Identify Casualty Collection Point (CCP)

Security• Internal / External security • Police bring wounded to CCP• Introduction of Fire EMS

R2TM Fire/EMS Overview

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Stage• Out of line of sight• Prepare for response entry

Link-Up• Establish Unified Command• Security escort

Enter Warm Zone• Begin MCI protocols

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• Immediate introduction of LE assets• Move quickly to last known area of

suspect / verification?• Understand “sweeps” vs. “clears”• What are immediate threat indicators?• FOB’s can be useful

LE Response


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• Does not require 100% confirmation of suspect location

• Fled, Dead, Captured• Once Immediate threat indicators have

lapsed, transition to victim assessment / retrieval

• Can continue sweep operations and CCP identification

Threat Mitigation


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• Brings stabilization to operations• Provides for dual operations• Aids UC and 9-1-1 point of contact on

interior• Increases efficiency of interior sweeps• Aids with decentralized tactics

FOB Purpose


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• When immediate threat indicators have subsided

• LE lockdown hallways, architectural features, large geographical areas

• Sets the stage for victim transfer • Minimal resource allocation can have

significant impact • Corridor lockdown builds on itself • Aids in scene stabilization

Corridor Lockdown


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• Paramount!• Needs to be physical is design • Sgt / BC ideal• Fire Understands / Police need to embrace and

execute • Only one location for UC• Don’t view UC as a monolithic entity

Unification of Commands


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• Efficient prioritization• Centralized location• Simple Concept • Manageability• Low cost• Enhanced Security• “Quick Connect”

Benefits

Casualty Collection Point


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• Provides a bridge between police and fire• Allows for simultaneous operations• Proven military tactic for categorization• Minimal UC Command & Control• Can have multiple CCPs if necessary and aids

in incident control– Use caution on adding unnecessary layers of ops



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• Law Enforcement Identifies • Fire Establishes • Not necessarily victim dependent • Ease of vehicle access / transport priority • Ability to Secure • Adequate Space• Should be located on the interior • Can establish CCP with barricade / hostage

CCP LocationKey Elements


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• Make a clean workspace– Identifiable treatment zones

• Reduce the desire to over complicate the MCI– i.e. Internal triage zone to external treatment zone

• Only essential personnel– “Greens” and other non-injured: elsewhere

• “Scoop and Run” vs. “Stay and Play”



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• Limited to rapid and easy intervention– i.e. Tourniquets– Follow TECC recommendations

• Victims transferred to CCP via LE– Hasty field triage

• Get critical patients to EMS first• Having LE transfer victims to the CCP is

resource driven and supported by the 9 principles of warfare

Hot Zone Medical Care


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• Extremely effective to combat extremity bleeding

• Easy to train and inexpensive• Studies indicate upwards of 90% associated

survival rate

Tourniquet Use

Kragh JF, Walters TJ, Baer DG, et al. Survival with emergency tourniquet use to stop bleeding in major limb trauma. Annals of Surgery. 2009;249: 1-7.


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• Stage resources out of line of sight• Limit first responding fire/EMS resources

– Reconnaissance; Pave the path• Take only needed equipment to get the job

done

Prepare for Entry


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• Request link-up over interoperable channel• Location to be out of hazard zone• Capable members

– Fire: officer, BC, Chief; LE: Sgt, Lt., Commander• Should be physical

– Cautious of non-physical link up• Simplify the ICS structure

Command Link-Up


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• Must have radio interoperability – Ability to talk and listen– Critical for intelligence, integration and safety

• LE and Fire/EMS should conduct entity specific operations on separate channels/frequencies– Do not impede critical operations

• Use short succinct communications

Communications Plan


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• Apparatus Security – Escort– On Engine– NFPA Guidelines

• Overwatch• CCP Security

Components of Fire Security


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• Will your triage method hamper time?• Triaged patients may shift categories on you• Fix major problems

– TECC guidelines– PHTLS

• Work trauma codes? • Monitor available medical resources

MCI Operations


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• Increase victim scene times

• Increases total out-of-hospital time

• Requires more resources

• Creates damage

Interference with Transport


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• Do not shift the MCI to another location– Refrain from blind transport (last resort only)

• Assign someone to communicate with receiving facilities– Example: Medical Resource Hospital

• Document as much patient info as practical– Use technology

Destination Etiquette


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• Stop further harm from occurring• What is the weather?

– Keep in doors if appropriate– No return: 32*C / 89.6*F

• Need for decontamination?

Environmental Concerns


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• Create a response that your jurisdictions can use on a daily basis– i.e. Assault

• Make sure your neighbors can plug in• Keep it simple and highly functional• Train on a reoccurring basis

– All hands on deck• This is a “three legged race”

Commit to the Response


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More info

• Craig Allen – [email protected]

• Jeff Gurske– [email protected]


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