06 - The Active Shooter Conundrum.

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As controversial as the subject may be, our personnel are preparing to put themselves in harms way to save lives.

We have an obligation to ensure these forward responders have the best tools and tactics to complete their mission safely. Utilizing SALT in an active shooter warm zone or cold zone environment would be detrimental to our responders, their patients and the mission objectives.

An MCI of a Different Color:

Policy states X number of patients equates to an MCI. This invokes our MCI response plan and inevitably means we use our standard MCI triage process. Logical but flawed. The exception to the rule, aside from HazMat, is active shooter. We have already developed unique protocols to implement for active shooter scenarios such as law/fire Unified Command at the ICS level and law protected Rescue Tasks Forces (RTF) at the tactical level.

We should equally consider the best process an RTF should utilize in warm zone operations to fulfill its mission objectives of hasty application of lifesaving intervention and rapid extraction of the injured to the cold zone Casualty Collection Point (CCP) for subsequent treatment or transport.

The RTF should not be tasked with the traditional triage objective of obtaining a patient count by acuity while operating in a warm zone. Doing so would detract from their mission and the resulting count information would have little or no impact on overall mitigation of the event.

The Lesser of Two Evils:

Pick your poison. Both SALT and START require a call for the walking to move. Often in tactical environments victims are better off sheltering in place as they may see threats we do not. The call could result in exposing them to the threat and alert the shooter of the RTF’s position. That rules out using any global sorting requirement for the walking.

The RTF law protection component will systematically move forward as they confirm an area is clear. If safe to do so, they will indicate the escape route to sheltering ambulatory victims as they are encountered. They then establish a force protection perimeter for the embedded RTF to begin treating and extracting patients. This then repeats.

The process the RTF implements to prioritize patient assessment should be situation dependent and determined by the RTF Leader on the ground. In some situation it may be best to use a START-like methodical combat casualty care process where patients are given a primary survey as they are encountered and treated if a life-threatening injury exists. In some cases it may be immediately apparent, especially in close quarters, which patients need care first. It may be that a seriously injured patient cannot be safely accessed so care is deferred to others. In the dynamic and unpredictable environment of active shooter warm-zone care the RTF should not be restricted by an algorithm when determining the best process to use for prioritizing treatment. This includes both SALT and START.

Triage Lite:

Warm zone triage marking should generally be restricted to the application either red or black/white ribbons to patients. This alerts extraction teams as to what patients have been deemed salvageable and which ones are not. Living/Dead counts should be relayed to command in real time if possible.

Update: Recent findings in Active Shooter drills with law enforcement has reviled that our LE counterparts often use Red to indicate a hazard, such as an IED. Red is the international standard for indicating a threat. (ANSI part Z535 Safety color coding standard.) This brings into question if we should be placing red ribbons on patients at all. Maybe a neutral color, such as Orange, would ensure Fire/Law interoperability. Check with your local LE agency and obtain their input before fixing your plan.

It’s a CCP thing...:

True MCI triage occurs at the Casualty Collection Point(s). In the safe cold zone we can apply an algorithm based triage system to prioritize patients for stabilization and obtain the acuity count.

So which system fits the bill? In active shooters it should be expected that the first injured patients encountered are those that self-evacaute. It is highly probable this ‘walking’ group has within it patients in need of immediate medical assistance. They should be assessed as encountered. That is a START-compatible process. SALT requires this group be assessed last.

Subsequent non-ambulatory patients will be littered to the CCP. Depending on the scale of the incident and resources available, the rate of patient delivery can range from a short trickle to a building surge. In either scenario we should triage patients as they are extracted and present. This again is a START-like process as we triage patients as they are encountered (Start-where-you-stand). There is no reason to invoke SALT’s discrimination against those with purposeful movements or no ‘obvious-life-threat’. These patients are unable to walk because they just came from a ballistic prone hot zone. They should be assessed immediately and prioritized for delivery to established treatment areas or transport.

So in these two instances we would need to change and violate SALT’s process to adapt it to a CCP. With START, we apply it the same way as we do in any other scenario. SALT is simply not conducive to CCP operations.

This unique ability of START to handle reverse triage (patients coming to us, usually the least injured first) makes it ideal for Hospital Surge Response to manage patients that self-transport and is the reason many hospital systems nationwide use it as such.

You’re Going to Need a Bigger Boat:

We deliberately limit the LSI items we carry into an MCI to avoid the temptation to deviate from the non-subjective algorithm and give excessive care thereby slowing triage down. Because granular triage acuity count is not a component of warm zone operations we should carry ample supplies to fit the mission objectives. It should not be a triage algorithm that dictates this but common medical sense. Occlusive and hemostatic dressings, pressure bandages, decompression needles and NPAs are all battle proven load-out components for ballistic MOI casualty care. Don’t forget Red and Black/white ribbons and a compact litter if available.

Shooting From the Hip:

Avoid falling into the lure of thinking that because LSI is needed in an active shooter and since SALT has LSI you need SALT. What you need is LSI equipment and a lot of it. More than is allowed by SALT. Don’t restrict the effectiveness and safety of your RTF by requiring them to follow a fixed process to complete their mission. They are the eyes forward. Allow them to employ the tactics they deem appropriate. Utilize Tactical Emergency Casualty Care (TECC) procedures and consider issuing appropriate PPE.   

One last word of warning: Never use both triage systems together. No human can memorize two separate algorithms and flip a switch to recall only one with clarity in high stress environments.

The World According to SALT:

The majority of active shooter incidents will be over by the time we arrive on-scene. As a cold zone operation with scene safety declared we approach it as any other MCI. The primary difference is that the patient generator was gunfire so we need to be cognizant that ballistic injuries are present.

SALT Scenario: You arrive at the scene of a cold active shooter in a shopping mall and are assigned to the first-in triage team. You make a call for the walking and several shoppers respond, some with gunshot injuries. You direct them to go to the engine just outside the main doors. You know they are headed to care - some old-school Captain broke the rules and assigned a couple assessment resources for that eventuality. Moving forward you take a turn to the right while your partner turns left. As you round the corner you see a female sitting on the floor holding her leg and crying for help. You survey the scene. Four patients appear to be still while five or six others are making purposeful movement. The still patients are your objective. You pick a path and head toward a still patient on the stairs to your left. You walk passed the girl and, not seeing any life-threatening injuries, make your way to the stairs and begin your assessment. You break the rules yourself this time and check for breathing first. Respirations look OK. You already checked his mentations when you approached - just like you did back in the START days, so that step’s done. No pulse, so he’s under 80. Not good. He must have a hole somewhere. A quick primary survey and there it is. A through and through to the thigh. Nothing your CAT can’t fix but this guy needs fluids onboard stat. Rescue 5 has your company’s ALS gear and IVs but last you heard it was in a TC on the way in. Red ribbon or grey? 5 might get there soon. Might. You switch to tac 9 to ask Triage Unit Leader to see if he has an update on arriving resources. Coms are down. As usual. Maybe switch to Command and ask the IC? He’s got enough going on. “Sorry buddy, you're Expectant. I have no idea when you’re gonna get that line.” As you approach the next still patient you hear Cummings from Rescue 5 over the radio ordering up a red treatment tarp. Oh well, bad guess. The rest of the still patients were Dead and none of the others you passed in the process had obvious life-threatening injuries. You make your way back the way you came, assesing those making purposeful movement. All Delayed. The one with the end of her foot shot off might have been a Minimal but it was a judgement call. You finally get back to where you started and notice the female you first encountered is now reclined and is no longer moving.

Why Did She Die?

Ponder that for a moment…

then click the thumbnail.


Obviously this scenario can cut both ways. Maybe bypassing the first patient saved the second. “Maybe”. But since when is it a good idea to change what we do based off that word? The point here is that when ballistic patient generators are involved, conducting a rapid primary survey on non-ambulatory patients as they are encountered makes sense. In fact, conducting a rapid primary survey in any MCI makes sense. It takes less than 30 seconds and can mean the difference between life and death and you get a patient count to boot. And this idea about passing by someone without some personal reassuring contact. Really? That’s not who we are. There is a broader point here, however. It has to do with SALT’s visual assessment process. For daily runs we cut away clothing for a reason. Clothing likes to hide things we need to address. We don’t cut away in an MCI which is why we rely on RPM. In lieu of X-ray vision, one would be hard pressed to ensure a patient had no life-threatening injuries simply by walking by and taking a gander.