First Responder Guide for Improving Survivability
Recent improvised explosive device (IED) and active shooter incidents reveal that some traditional practices of first responders need to be realigned and enhanced to improve survivability of victims and the safety of first responders caring for them. This Federal, multi-disciplinary first responder guidance translates evidence-based response strategies from the U.S. military’s vast experience in responding to and managing casualties from IED and/or active shooter incidents and from its significant investment in combat casualty care research into the civilian first responder environment.
Additionally, civilian best practices and lessons learned from similar incidents, both in the United States and abroad, are incorporated into this guidance. Recommendations developed in this paper fall into three general categories: hemorrhage control, protective equipment (which includes, but is not limited to, ballistic vests, helmets, and eyewear), and response and incident management.
Hemorrhage Control
First responders should incorporate tourniquets and hemostatic agents as part of treatment for severe bleeding (if allowed by protocol). Tourniquets and hemostatic agents have been demonstrated to be quick and effective methods for preventing exsanguination from extremity wounds (tourniquets) and other severe external bleeding (hemostatic agents).
First responders should develop and adopt evidence-based standardized training that addresses the basic, civilianized tenets of Tactical Combat Casualty Care (TCCC). Training should be conducted in conjunction with fire, emergency medical services (EMS), and medical community personnel to improve interoperability during IED and/or active shooter incidents.
Protective Equipment
First responders should develop inter-domain (EMS, fire, and law enforcement) Tactics, Techniques, and Procedures (TTPs)—including use of ballistic vests, better situational awareness, and application of concealment and cover concepts—and train first responders on them.
As technology improves, first responders should adopt proven protective measures (e.g., body armor) that have been demonstrated to reliably shield personnel from IED fragments and shock waves.
First responders, when dealing with either IED or active shooter incidents, must remain vigilant and aware of the potential risk posed by secondary IEDs or additional shooters.
Response and Incident Management
Local and state law enforcement and emergency services should institutionalize National Incident Management System (NIMS)-based command and control language through plans and exercises and during ongoing education and training.
Local and state emergency management, EMS, fire, and law enforcement personnel and receiving medical facilities should have interoperable radio and communications equipment.
Local, state and federal partners should consider expansion of Public Safety Answering/Access Point (PSAP) intake procedures to include information gathering vital to the initial response.
Training to improve first responder triaging precision is essential for dealing with IED and/or active shooter incidents.
There should be greater coordination among EMS, fire services, and law enforcement to work more effectively during IED and/or active shooter incidents. The dialogue should focus on potential improvements or changes to the TTPs which have historically been used during law enforcement situations that involve a medical emergency (e.g., EMS waits until law enforcement secures the scene before they enter to render emergency care).
The recommendations presented—early, aggressive hemorrhage control; use of body armor and a more integrated response; and greater first responder interoperability—will help to save lives by mitigating first responder risk and by improving the emergent and immediate medical management of casualties encountered during IED and/or active shooter incidents.
Recent improvised explosive device (IED) and active shooter incidents reveal that some traditional practices of first responders need to be realigned and enhanced—with an emphasis on early hemorrhage control and a more integrated response by first responders (i.e., emergency medical services [EMS], fire, law enforcement, and rescue personnel)—to improve survivability of victims and the safety of first responders caring for them. At the request of first responders and first receivers (e.g., medical technicians, nurses, and physicians) who have encountered mass casualties from IEDs and/or active shooter incidents, this document was developed to provide guidance on how to better approach these incidents.
Responders should also consider the combination of both IEDs and active shooter incidents in an organized, complex attack (such as the Mumbai attacks in 2008) that requires both treatment and extraction of the injured from a still-hostile environment. The conditions during such tactical assaults in a civilian setting speak to the need for first responders and first receivers to adopt evidence-based hemorrhage control, risk evaluation, and casualty management measures in a potentially dangerous environment.
As a result of these developments, the Department of Homeland Security, in coordination with the Department of Defense (DoD), Department of Health and Human Services, Department of Justice, Department of Transportation, White House Office of Science and Technology Policy, and the National Security Staff, has developed recommendations for individuals who provide emergent and immediate medical management of casualties resulting from IEDs and/or active shooter incidents. Based on best practices and lessons learned, this document focuses on the medical response to IEDs and/or active shooter incidents with recommendations for hemorrhage control, protective equipment (which includes ballistic vests, helmets, and eyewear), and response and incident management.
