Mass Casualty/Fatality Management in the Age of the Active Shooter

BCFS Health and Human Services

BCFS HHS is one of six corporate entities within the BCFS system of non-profit companies. Programs and services include:Emergency management planning and incident response

Medical and mental health services

Residential services for adults with cognitive/developmental disabilities

Social services

International humanitarian aid and medical teams

Management and support services to other non-profit organizations

BCFS HHS Emergency Management Division• Medical Sheltering

• Mass Care Planning

• All-Hazard IMT

• Base Camp Operations

• Medical Staffing

• Immediate Disaster Case Management

• Jurisdictional Consultation, Training and Plan Development

• Private Sector Response and Policy/Plan Development

3

Large Incident Response• Branch Davidian Incident

• Southeast Asia Tsunami

• Hurricane Emily

• Hurricane Katrina, Rita

• Eagle Pass Tornado

• Hurricane Dean

• FLDS Event

• Hurricane Dolly, Gustav, Ike

• H1N1 Flu

• Haiti Earthquake

• Hurricane Alex

• Texas Wildfires 2011

• Ebola Outbreak

• USHHS ORR Influx 2012, 2014, 2015, 2016

• Sutherland Springs Massacre

• Hurricane Harvey and Maria

4

Active Shooter Background

Historical Statistics2013 - 2018 mass shootings in the U. S. (all incidents where 3 or more victims are killed in a public space, excluding deaths that came as part of crimes like a robbery or gang violence)

2013 – 1176 wounded, 467 killed

2014 – 1213 wounded, 364 killed

2015 – 1387 wounded, 469 killed

2016 – 1636 wounded, 626 killed

2017 – 1981 wounded, 590 killed

2018 (to date) – 631 wounded, 242 killed

Source: A Guide to Mass Shootings in America, Mother Jones and the Foundation for National Progress

Profiling the Shooter• Mental health - of 95 of the largest mass shooting studied, signs of

mental health issues◦ yes – 50

◦ Probable - 9

◦ Unclear – 16

◦ No - 14

• History of domestic abuse

• History of childhood abuse

• Alcohol and drug abuse increase violent crimes 7 fold

• 85% of shootings occur within a social network

• Male gender

Source: American Journal of Public Health 2015: Social Psychiatry Epidemiology, Von Dora, et. Al, 2012; Papachrist et al, Social Networks and the Risk of Gunshot Injury, J Urban Health 2012

Ethnic Background

• White – 62%

• Black – 16%

• Latino – 7%

• Asian - 7%

• Native American – 3%

• Other/unknown – 5%

Source: Mother Jones’ Investigations, US Mass Shooting, 1982 - 2017

Dimitrios Pagourtzis ( Santa Fe)

Where Does it Happen?

Target Considerations• Venues

◦ Workplace – 30◦ Schools – 15◦ Military – 5◦ Airport – 1◦ Other - 38 (shops, concert, club, restaurants, theaters)

• Places of worship/theaters/clubs◦ Soft target◦ Concentrated grouping of victims◦ Limited escape routes◦ Likely to have children and elderly

• Mass Gatherings◦ Potential for significant number of victims◦ Mass confusion and panic◦ Difficult to secure every venue◦ Medical surge issues

Source: Mother Jones’ Investigations, US Mass Shooting, 1982 - 2017 San Bernardino, L.A. Times/Barbara Davidson

Sutherland Springs

Weapon of Choice

• Semi Automatic Rifles (AR-15, AK-47, – Aurora, Roseburg, San Bernardino, Newtown, Orlando, Las Vegas, Sutherland Springs

• .45 caliber or 9 mm Semi-automatic handgun

• Of 95 shooting studied between only 15 did not use semi-automatic or assault type weapon

Source: Gun Violence Archive

Aurora, Denver Reuters/Evan Semon

Average length of time of Incident

• 70% of the events ended in 5 minutes or less.

• Average 8 - 12 minutes in duration, with an average of one person being shot every 15 seconds

• In at least 65 (40.6%) of the 160 incidents, citizen engagement or the shooter committing suicide ended the shooting at the scene before law enforcement arrived

Field Response

Sutherland Springs Massacre 11/5/17• Devan Kelley arrives at church at 11:20 a.m. • Began shooting out side of church - killing

two• Then entered the church• Shooting in church lasted approximately 6

minutes (15 empty magazines in church found each capable of holding 30 rounds)

• Kelley exited church• Engaged in exchange of gun fire with

Stephen Willeford• Kelley takes off in car• Followed by Willedford and Johnnie

Langendorff• Crashed during high speed chase• Found dead in vehicle

Johnathan Becjan/Reuters

(David J. Phillip / AP)

Response

• Wilson County EMS first on scene

• Callout did not immediately identify situation other than shooting with multiple injuries

• Immediate medico-legal authority was local Justice of the Peace

(Mohammad Khursheed / REUTERS)Associated Press

The Tragedy Unfolds

• 20 injured

• 26 killed

◦Pastor’s daughter

◦Eight members of one family

◦Victim ages ranged from 0 - 77

years old

◦Ten women, seven men, seven

girls, one boy, and one unborn

childDavid J. Phillips/AP

Las Vegas Shooting

• Duration – 12 minutes

• Weapons – AR-15

• 58 dead, +850 injured

• Delayed EMS response due to unknown location of shooter

• Overwhelming number of injured/dead

• Majority of injured not triaged in field

Ibtimes.co.uk

Mcleans.ca

Three Phases of MCI – Medical Sequelae

• The largest number of deaths occurs in the Initial Phase due to injuries incompatible with survival.

• The largest number of preventable deaths occurs in the Second Phase, occurring minutes to hours following the MC. The key medical issues during the Second Phase are:◦ rescue of the victims

◦ provision of timely first aid

◦ early evacuation of patients with life and limb threatening injuries to medical facilities.

• Third Phase – occurs days to weeks following the disaster. ◦ treatment of late medical complications such as sepsis, multiple

organ failure

◦ Psychological sequelae of the incident

Pediatrics

• Head injuries account for 60% of all MCE and disaster injuries in children – head size relative to body

• Small amounts of blood in body (80 ml/kg) = minor bleeding can be more significant and lead to more rapid shock

• Children tolerate multiple organ injuries better than adults and the prognosis usually depends on severity of head injury

• Can’t triage children using usual triage criteria (ability to walk and ability to understand verbal commands)

• Israeli model prioritizes shock as critical immediate for pediatrics and in the delay group anxiety and acute emotional stress

Triage Principles in Multiple Casualty Situations Involving Children – the Israeli Experience, Mor and Waisman

Israeli Mass Casualty Algorithm for Pediatric Triage

Triage Principles in Multiple Casualty Situations Involving Children – the Israeli Experience, Mor and Waisman

Rethinking Triage and Initial Response• Traditional START delays treatment and transport Columbine/

LAX)

• Traditional EMS response not effective in active shooter scenarios

• Look to military tactical combat casualty care model

• Tactical Emergency Medical Support (TEMS) medical training for police officers

• Use of Tactical Emergency Casualty Care (TECC)

First Responder Guide for Improving Survivability in Improvised Explosive Device and/or Active Shooter Incidents,

Department of Homeland Security, Office of Health Affairs 2015

Tactical Emergency Casualty Care (TECC)• Integrated, rapid, law-enforcement-directed responses (EMS embedded)

• Limited equipment, limited patient assessment and limited treatment

• Hot zone: direct threat care – move wounded to cover, manage massive hemorrhage utilizing tourniquets

• Warm zone: indirect threat care - casualty is in area of relative safety (proper cover or a cleared but not secured area)

• Cold zone: evacuation care by moving patient towards a definitive treatment facility

• Medical Management differs from usual A,B,C’s◦ M – massive hemorrhage control◦ A – airway support◦ R- respiratory support◦ C - circulation◦ H – head and hypothermia

First Responder Guide for Improving Survivability in Improvised Explosive Device and/or Active Shooter Incidents, Department of

Homeland Security, Office of Health Affairs 2015, IAB Active Shooter Hostile Event Guide)

Barriers to Implementation

• Concerns about provider safety

• Territoriality

• Perceived lack of adequate staff

• Concerns about training/ equipment sufficiency

• Collective bargaining restrictions on responsibilities

• Inability to agree on a collaborative response and training framework between law enforcement, fire/rescue, and emergency medical services (EMS)

Dhses.ny.gov

Hospital Response

Case Study – Las Vegas Shooting• Initial triage done at hospital, not in field

• Assessment by clinical judgement - assess GSW (trajectory and subsequent injuries)

• Choke areas – flow to operating room, waiting for neuro surgery. Head GSW were tubed, CT scanned, trauma ICU.

• CT – chokepoint. Formed a CT “conga line”

• X-ray – radiologist embedded in ED

• Cycling of decompensation – oranges to red, yellows to orange

• Ran out of thoracotomy tray/chest tubes- used ET tube

• Nurses carried their sux and etomidate, in pockets

• Vents – double tidal volume and Y tubing - 2 people on one

How One Las Vegas ED Saved Hundreds of Lives After the Worst Mass Shooting in U.S. History, BY KEVIN MENES, MD, JUDITH TINTINALLI, MD, MS AND LOGAN PLASTER ; Emergency Physician Monthly, Nov. 3, 2017

Post Event

Immediate Post Event Crisis Management - PsySTART

• Site based individual rapid triage decisions for emergency mental health interventions

• Floating triage algorithm

• Allows for high-risk individuals to be match to brief, evidence based care

• Does not require a mental health professional to complete

• Measures traumatic exposure, traumatic loss, injury/illness, and secondary stressors

• Risk level – green, yellow, red, purple (danger to self or others)

Source; 2010, Schreiber/The PsySTART Mental Health and Incident Management System

Initial Support After the Incident

• Hotwash immediately after incident

• Critical incident stress management (CISM)

• Reduce re-traumatizing responders, staff

• Family of staff may need support

• Delayed psychological effects can occur months or years later

Sutherland Springs Recovery

Immediate Aftermath

• Media frenzy

• Multiple agencies flood area

• Local government entities inundated

• Families overcome with magnitude of tragedy

• Deluge of donations

• Volunteers rush to area

• Investigation turned from local medico-legal authority to Texas Rangers and FBI

Mark Ralston/AFP/Getty Images

Mark Ralston/AFP/Getty Images

• Wilson County Sheriffs Office

• Wilson County OEM

• Wilson County Fire Marshals Office

• Wilson Judge

• Wilson County Commissioners (4)

• Wilson County JP (4)

• Wilson County Constables Office (2)

• Wilson County DA

• Wilson County EMS Director

• Wilson County ESD (2)

• Stockdale Volunteer Fire Department

• La Vernia Volunteer Fire Department

• La Vernia EMS

• La Vernia Police Department

• Acadian Ambulance

• St. Hedwig Fire Department

• New Berlin Fire Department

• Texas Rangers

• Texas Public Safety Troopers

• Texas Dept. of Public Safety Intelligence

• Texas Dept. of Emergency Management

• Texas Dept. of Transportation

• U.S. Dept. of Homeland Security

• FBI, Law Enforcement

• Alcohol, Tobacco, Firearms (ATF)

• Immigration and Customs Enforcement

• FBI Joint Terrorism Taskforce

• FBI Evidence Collection Team

• STRAC

• Methodist Air Care

• Air Life

• Atascosa County Office of Emergency Management

• Atascosa County Fire Marshalls Office

• Atascosa County Sheriffs

42 Response Resources

Recovery

• BCFS HHS received two requests◦ TDEM to assist county

◦ First Baptist Church

• County Emergency Management overwhelmed

• No church governance remained in place

• No one to release scene to after law enforcement finished investigation

• BCFS System President met with Associate Pastor, DDC, Wilson County, County Judge, District Attorney, County Sheriff, DPS, TDEM

On-Scene Management

• On scene resource logistics

• Maintain security

• Church remediation

◦ Remediation of grounds, sanctuary

◦ Clean up construction crews

◦ Disposal of church furniture/equipment

◦ Installed lighting, secured church

◦ Developed memorial

• Managed on scene media and public information

• Monitored media outlets, including social media

Evolving Mission – Support the Church

• Support church◦ Facilitated discussions about remediation of church

◦ Transfer of phones/website

◦ Managed mail/sorted (1000’s of letters/emails daily)

◦ Tracked requests to provide assistance

◦ Coordinated calls with County

◦ Media management/statement preparation

◦ Handled finances/ donations

◦ Assisted with establishing church governance

◦ Coordinated alternate services location

◦ Assisted with funerals

◦ Assisted with victim housing servicesDavid J. Phillips/AP

Community Support• Started with Victim Assistance Center

• Morphed into Disaster Recovery Center model

• 24/7 Victims Assistance Helpline established

• Overhead support for DRC (set up, security, food services for staff)

• Allowing first responders to re-visit the scene

• Tracked social media posts

• Managed self deployed volunteers

Reuters Photo

Alternate Church Services

• Church wanted services the following Sunday

• IMT coordinated logistics

◦ Site Plan

◦ Food

◦ Tents

◦ Traffic flow

◦ Traffic control through DPS

◦ Security

◦ Fire and EMS staged on scene

◦ Liaison with VIPs and public information

Memorial Service Site

• Set up memorial

• Audio loop

• Security

• Manage media and public information

• Traffic flow

Take Aways

Access Kit

• Ability to open lockable doors (master key)

• Facility floor plan (“here you are” evacuation plan)

• Hospital radio

• Trauma supplies◦ Tourniquets

◦ Hemostatic agent

◦ Compression dressings

First Responder and Community Coordination

• Situational awareness if not just for responders anymore

• “Educate everybody because we can not protect everybody”

• Coordination, collaboration and communication

• Working with and engaging community leaders vested in protecting their own community, - highlight transparency, trust, and information sharing

Health and Medical Response to Active Shooter and Bombing Events; John L. Hick, Dan Hanfling, Bruce Evans, Sheldon Greenberg, Roy Alson, Suzet McKinney, and Matthew Minson; June 17, 2016

Community Involvement

• First on scene will be the people that are there when it happens

• Promote civilian medical interventions, CPR, and the location of Public Access Trauma Kits (PATKs) training.◦ skills to stop external bleeding

◦ provide basic airway management and body positioning

◦ recognition of chest injury affecting respiratory function

◦ effective and efficient patient movement

◦ prevention of hypothermia

◦ psychological support for the wounded IAB Active Shooter/Hostile Event Guide

David Becker/Getty images

John Tlumacki/Getty Images

Engaging the Community• Educate/train non-traditional parties

(churches, businesses, event vendors)

• Prevention by identifying, assessing, and managing potential threats. Recognizing pre-attack warning signs and indicators

• Community training◦ “See something, Say something”

◦ Active by-stander training (Stop the Bleed)

◦ Train groups that congregate

• Threat assessment teams

• Develop a plan

Questions?

Dee Grimm RN, JD

Director of Business and Program Development

Emergency Management Division

BCFS Health and Human Services

dgrimm@bcfs.net

210-216-0930