control can be easily integrated into mass casualty triage training. In
addition to robust initial training, the low-frequency, high-consequence
nature of these incidents makes it equally important to have ongoing
training programs to help ensure that personnel retain these skills.
In addition to education and training for EMS personnel and professional rescuers, EMS agencies can incorporate public-access hemorrhage
control training into community events, civic group meetings, and existing hands-only cardiopulmonary resuscitation training programs.
An EMS system’s readiness to respond to active shooter and intentional
mass casualty events necessitates rapid access to specialized medical
equipment. This equipment includes, but is not limited to, hemorrhage
control devices, such as commercially available tourniquets and hemostatic dressings.
Customary practice for many EMS agencies is to centrally stockpile
mass casualty equipment. However, given the immediate need for this
equipment in the moments following such incidents, such stockpiles
will likely not be mobilized with enough time to be clinically useful.
Prompt access to lifesaving equipment requires strategic pre-placement,
including the addition of these items to standard ambulance and first
responder vehicle inventories. Some public safety agencies have elected
to pre-deploy equipment caches in areas of high occupancy and mass
gatherings, similar to the location of automatic external defibrillators.
Other essential medical equipment is recommended in resource documents, including the U.S. Department of Homeland Security’s First
Responder Guide for Improving Survivability in Improvised Explosive Device
and/or Active Shooter Incidents. 3 Specialized logistical equipment, including patient-extraction devices, as well as ballistic and personal protective
equipment also may be warranted. Further discussion regarding additional equipment selection is beyond the focus of this article.
Prehospital EMS systems represent an essential component of a comprehensive trauma network. Preparedness and response to active shooter
and intentional mass casualty events require an adaptation of current
EMS system practices that must at all times be balanced with a threat-based approach to operational and clinical actions. Having an enhanced
preparedness for such incidents will heighten a region’s resilience and
improve the EMS system’s ability to handle casualties from all hazards. ♦
The success of such programs requires partnership and
commitment between EMS and law enforcement agencies
well ahead of an incident and should not haphazardly be
implemented during the incident.
1. National Association of Emergency
Medical Technicians. TCCC
guidelines and curriculum.
Available at: www.naemt.org/
curriculum. Accessed June 17, 2015.
2. Committee for Tactical Emergency
Casualty Care guidelines. Available
at: www.c-tecc.org. Accessed June
3. Office of Health Affairs. U.S.
Department of Homeland Security.
First Responder Guide for Improving
Survivability in Improvised Explosive
Device and/or Active Shooter
Incidents. June 2015. Available
Accessed June 30, 2015.
4. Maryland Institute for Emergency
Medical Services Systems. 2015
Maryland Medical Protocols for
Emergency Medical Services
Providers. Available at http://meiss.
tabid/106/ default.aspx. Accessed
June 17, 2015.
5. U.S. Fire Administration, FEMA.
Fire/Emergency Medical Services
Department Operational Considerations
and Guide for Active Shooter and Mass
Casualty Incidents. September 2013.
Available at: https://www.usfa.fema.
June 30, 2015.