Police as Medical Responders in Active Threat Events

April 20, 1999, was a bellwether day in American law enforcement history. An act of mass murder occurred at Columbine High School in Colorado that left 13 people dead and 21 injured, and the old model of responding to active threat events was changed forever. The active pursuit of the killer would no longer be a Special Weapons and Tactics (SWAT) problem to solve – it would be a first-arriving officer’s problem. Fast forward 18 years and the mass killing event at Florida’s Marjory Stoneman Douglas High School shows how far the nation has come and needs to go to prevent more deaths.

In the aftermath of the 1999 Columbine High School mass shooting, there was a paradigm shift in the way police in the United States responded to active shooter events. In short order, rapid law enforcement deployment using the first responding officers to enter the crisis site and engage the killer(s) became the new paradigm. Officers deployed into the crisis site to provide 360-degree protection as they moved through the target to confront the threat.

The Old Model

In the old model, officers would establish a perimeter, contain the suspects, and await SWAT teams to resolve the issue. When the person(s) committing the act of mass murder only wants to kill, the old response model results in more death. A basic tenant of previous active shooter response plans was to bypass injured and dead people in order to rapidly confront the shooter and end the threat, either by law enforcement eliminating the threat, suicide of the offender, or the offender’s surrender. The next step in that process was to secure the location and conduct a thorough search for other suspects or threats. The injured and dying were an afterthought.

In the old model, police would not allow fire and emergency medical services (EMS) into the crisis site to render aid. This policy was based on the belief that the medical aid providers lacked training, ballistic-protective equipment, and the tactical mindset to enter the area where the shooting had just occurred. While police are concerned with suppressing the threat and securing the scene, the rapid response model does nothing for those people bleeding and dying. To this point, law enforcement officers were and still are trained to deliberately avoid engaging in patient care activities.

The U.S. Fire Administration published a report that dissected the Columbine shooting and indicated many changes that needed to occur in the response to mass killing events. One of those suggestions was a closer partnership between law enforcement and fire/EMS, as well as better emergency medical training for law enforcement. Unfortunately, it would be more than a decade before any concrete steps were taken toward those ends.

The Current Model

The next evolution of active threat response and care saw the development of the Rescue Task Force (RTF). RTFs combine law enforcement and fire/EMS into a single unit with the purpose of pushing into the warm zone and providing life-saving patient care and evacuation, before the target location is secure. Many drills and actual events have revealed that, while RTFs have a valid purpose and vital need, victims in active killing events are still dying from severe bleeding and could be saved if care was rendered sooner. To that end, law enforcement contact teams need to be trained and equipped to switch roles from suppressing/ending the threat to rendering medical aid to those casualties who have significant penetrating trauma but are capable of being saved.

Two decades of war in Afghanistan and Iraq have yielded a tremendous amount of data and research on the benefits of some simple emergency care tasks that control life-threatening bleeding. The U.S. military has invested vast amounts of time and money in developing and advancing Tactical Combat Casualty Care (TCCC) and pushing that knowledge into the civilian world. The current doctrine within the U.S. Army’s 75th Ranger Regiment is to train all members of the unit in TCCC. The rate of preventable combat death within the regiment is less than 3%.

American law enforcement officers are learning the skills included in TCCC, as well as the civilian version, Tactical Emergency Casualty Care (TECC), and the national Stop the Bleed (STB) campaign in order to shift focus during the response to emergency medical care. During the shooting at Marjory Stoneman Douglas High School on 14 February 2018, 17 people were shot to death and 17 others were wounded. Of the 17 who survived, all were initially treated by police officers using equipment that they had on their person. Once it was determined that the shooter was not in the immediate area, the officers switched focus and without doubt saved lives.

In the aftermath of the mass shootings at Virginia Tech in 2004 and Northern Illinois University in 2008, police also shifted roles from warrior to caregiver. Officers at Northern Illinois were unique in their response in that they were all trained and certified as emergency medical technicians (EMTs). Officers must be equipped, trained, and prepared to switch roles as soon as the threat is neutralized or no longer present.

The Future Model

The advent of the RTF model and its increasing acceptance by police and fire/EMS departments is laudable and should continue to be developed and nurtured. However, the people charged with developing responses to active shooter/threat events must consider how to deliver emergency medical care at the same time. The threat continues to evolve, and with the lessons learned from each event, the responders must evolve as well.

Those charged with developing active shooter/threat events responses must consider how to deliver emergency medical care at the same time.

One of the drawbacks to the RTF model is that it takes time for both police and fire/EMS units to arrive and stage. Even the most robust and well-trained RTF programs can take 10-15 minutes to establish the initial RTF and enter the crisis site. In that time, victims continue to bleed and die. To counter the time delay between wounding and initial medical care, law enforcement needs to take on the mantle of providing life-saving medical care.

In 2016, a regional Level 1 trauma center and a city police department in central Illinois partnered to create a training model using the TCCC principles to meet the needs of their jurisdiction. In addition to learning these skills, officers completing the training were issued a Combat Application Tourniquet (CAT), Combat Gauze™, a SWAT tourniquet and nitrile gloves. The original goal of the training program was for self-aid/buddy-aid, yet it quickly showed its benefit for victims of crime and accidents.

Although it was initially developed for one agency, it rapidly spread to all police departments in the county. Within a month of the training there were several instances in which police officers saved lives with the skills and equipment provided. Since then, the training has been requested by law enforcement agencies outside of the original county and even by some state-level law enforcement agencies.

A Call to Action

Modern law enforcement officers have many things asked of them and are placed in high-stress situations regularly. The most stressful of those situations is an active threat event. The officers responding will be confronted with the threat to their own safety, but also with the scared, injured, and dead victims of the offender. Fear and anxiety are often born out of one’s lack of training or knowledge in dealing with or confronting a situation.

Law enforcement officers need to be provided with training and equipment that will enable them to switch gears in an active threat event. Once the threat is suppressed, contained, or eliminated, police need to be able to recognize life-threatening injuries that can be treated with simple skills, such as severe bleeding and correctable airway problems. It has been demonstrated that police officers providing initial medical care in the active threat environment, prior to the assembly and deployment of RTFs, equates to increased survival of victims who otherwise may not survive.

If an agency or jurisdiction is unable or unwilling to provide this simple life-saving training, individual officers need to seek out the training themselves. A good place to start, whether as an individual or as an agency, is https://www.dhs.gov/stopthebleed. Also, do not hesitate to reach out to local hospitals, healthcare coalitions or community groups to provide the training or funding for the training.