When was the last time you thought about a mass-casualty incident? Most departments rarely train for MCIs, yet the potential for them is there every day.
In my department we participate in an annual exercise at the Cincinnati-Northern Kentucky International Airport as one of approximately 40 medic units staged to demonstrate patient-transport capability. There also are opportunities for hands-on triage training at one of the several hospital re-certifications. We also are a part of the region's mass-casualty response team, whose practices focus on big events such as an airborne contaminant at the city's Great American Ball Park, which would affect thousands of baseball fans. At tabletop exercises, incident management teams discuss such things as the use of Cincinnati's bus system or school buses for the orderly transport of the walking wounded to various treatment sites or hospitals.
To some, their mental pictures of MCIs are things such as two commuter trains smashing into each other, or an aircraft crashing short of the runway. You need only to look at Fox News or CNN for the latest examples of what are the real bread-and-butter MCIs. Surprisingly, most of these are in less densely populated areas served by combination or smaller career departments.
In March, 11 people were killed in a rural Alabama neighborhood, and one was killed and two were injured at a church in Illinois, by gunmen during mass shootings. While it appears that both gunmen were targeting specific individuals, the Alabama gunman reportedly fired more than 250 rounds, many indiscriminately, hitting bystanders and intended victims alike. On average, the gunmen in mass shootings kill or injure a new victim for every five seconds they remain unchallenged.
No matter where we are, all of us have school buses carrying students back and forth throughout the day or evening. An MCI may involve such a school bus with multiple injuries involving children. A department in Kentucky responded to such an accident this past winter when a school bus was struck by a car, which forced the bus into the side of a home. Fortunately, the children were not seriously hurt and, at the direction of their driver, used the emergency exit to quickly leave the vehicle. I know my heart would sink if I arrived and saw the rear of school bus protruding from the side of a 2-story residence. Chances are the fire and EMS responders knew at least some of the children or the families involved.
Another department, this time in Indiana, recently faced a major challenge with a 32-vehicle crash on a major interstate highway during a whiteout snowstorm. The resulting chain reaction required six simultaneous extrications with three fatalities, 12 serious injuries and 18 walking wounded. One of the department's engines also was struck after it arrived at the scene. Fortunately the crew was far enough away and wearing their reflective vests, which enabled them to avoid injury.
In both these instances, the departments used their mutual-aid, multiple-alarm assignments to bring the additional resources needed to handle the emergencies. While both of these incidents involved the three Ts — triage, treatment and transport — I began to wonder, as a command officer, how the troops faired under these very trying circumstances. When do we need to rotate crews away from the site, and when do we need to set up a critical incident stress debriefing on site, even if it is just the ability to have a few words with the department chaplain?
As a member of the fire-service advisory committee at our local career-development institute, I was asked in mid-November to attend a three-day course entitled "School Shootings: Prevention, Response and Mitigation." The course was expertly taught by both a retired police chief and several retired federal agents. It gave the history, motivation and analysis of multiple-victim shootings at schools throughout North America, with special emphasis on the Columbine and Virginia Tech attacks.
Of the 35 attendees, only four were from the fire service, and we had to overcome at first the learning curve regarding police tactics in dealing with such events. Equally difficult to comprehend was the subculture that exists, via the Internet, that in some cases instructs, openly discusses and borderline promotes school shootings by teens as a way for a student to get even, while forever making his name infamous to the world.
As the course continued, it reinforced fire-service members' belief that the sooner medical triage and treatment is started, the greater the chance for victims to survive. At Columbine, for example, it took more than three hours for law enforcement to clear the building, during which time at least one victim, seen several times at an upper floor window, bled to death. In their defense, the SWAT teams knew neither the exact number of shooters nor the extent of the explosive devices planted throughout the building.
Once the review of historic scenarios was completed, the class discussion centered on how fire, EMS and law enforcement could better prepare and work comfortably in an ongoing environment that may be contained but not fully secured. We discussed the difference in these two concepts and how the military provides a perimeter in which combat medics can operate in hostile zones to commence the initial treatment of seriously wounded comrades.
One example cited three volunteer EMTs (college students, not SWAT members) who agreed to go into the stairwells at Virginia Tech to triage and treat victims brought to them in a controlled setting, while the SWAT teams continued to sweep the area for the shooter, who later was found dead among his victims. It was stated that from the time the EMTs entered the building, no other victims died. The EMTs did not use sophisticated equipment, just basic treatment bags to control bleeding and render first aid. They concentrated on bleeding rather than the standard ABCs, because all of the victims suffered from gunshot wounds.
With the conclusion of this course, we've started a dialogue in our area on how we can best respond and mitigate such carnage. We've begun to investigate the small, very compact first-aid kits carried by combat medics and soldiers in Iraq and Afghanistan as one possible solution. These kits carry trauma dressings, clotting substances and one-person tourniquets. But perhaps more important is the concept of providing a cleared perimeter, rather than a secured building, before treatment begins. This will require discussion, understanding and practice with your law-enforcement counterparts regarding a coordinated response to school shootings.
Upon doing so, you soon will have a keen awareness that most of us are ill-prepared, both procedurally and emotionally, to handle this type of emergency. I am not suggesting that every EMT or medic should be an armed member of SWAT. Some of us already provide tactical vests for our people due to the frequency of violent incidents, so is it a far stretch to allow them discretion to enter just after SWAT has swept an area and have other officers present to provide security for triage, treatment and transport of the victims?
Before you say "never," consider how well you are prepared to handle such a major incident at a school, knowing that on average another person will fall victim every five seconds a shooter is in the building, and those victims may be the friends, neighbors or the children of your responders?
If you haven't squirmed in your seat by now, then know that I did for nearly the entire three-day class. But I also came out of those sessions knowing we must have this discussion to be better prepared to respond to the unthinkable mass-casualty incident in our area. I am trying to get additional fire chiefs to attend one of the upcoming sessions on school shootings. If that occurs, we can build a consensus on how to approach both law enforcement and the schools on proposed changes for treatment of victims. If your department responds to only one school district, consider yourself lucky. My department provides advanced life support to three separate school districts and, under mutual-aid, as the second medic in two more.
The course, "School Shootings: Prevention, Response and Mitigation," soon may be available to fire and law enforcement nationally. The three days that I spent in class changed my thinking on MCIs. Whether yours is a career, combination or volunteer department, you need to give serious thought as to how you will respond.
Chief Robert R. Rielage, CFO, EFO, MIFireE, is the chief of Wyoming (Ohio) Fire-EMS, a 78-member combination fire department bordering Cincinnati. He previously served as the fire marshal of the state of Ohio. A graduate of the Kennedy School's Program for Senior Executives in State and Local Government at Harvard University, Rielage holds a master's degree in public administration from Norwich University and is the immediate past-president of the Institution of Fire Engineers-USA Branch. He is a member of the FIRE CHIEF Editorial Advisory Board.
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