We can save more lives in large scale active shooter situations, but it will require us to rethink everything we've been teaching EMS providers about scene safety.
On April 20, 1999, I sat in my ambulance and listened to the radio while Dave Sanders slowly bled to death a few hundred yards away.
It wasn't an oversight.
We knew he was there. Inside Columbine High School, a fellow teacher had scrawled the message "1 bleeding to death" on a piece of paper and placed it in a window.
Police were aware of Sander's location and his situation. Inside the classroom a small vigil of students, the same students Sanders helped to protect, gathered around him and showed him pictures of his three children while he slowly faded from consciousness.
As the note in the window predicted, the 47-year-old computer science teacher did bleed to death. On the day of the Columbine Massacre, we failed Dave Sanders. For that reason, I'll never be able to forget him.
Lessons of Columbine
Fortunately, a lot has changed in law enforcement since 1999. The lessons of Columbine spurred the creation of law enforcement rapid intervention teams and policies that allow officers to quickly engage violent attackers. Their success has been instrumental in stopping many of these incidents in minutes, instead of the hours that passed at Columbine.
Part of doing this work is analyzing our failures and finding the keys to better performance in the future. When it comes to active shooter events, law enforcement is now 20 years ahead of EMS. The evolution of law enforcement has been tremendous. However, if it happened again today, most systems across the United States would consign me to the same role I played almost 20 years ago, sitting idle in my medic unit and waiting for someone to declare the shooter or shooters dead and the scene clear.
When articles appear promoting the idea of an EMS rescue task force, to enter these scenes and help extract wounded victims during the incident, while police are still engaging the shooter, the ideas are met with a predictable barrage of scene safety advocates calling the idea ludicrous and reckless.
Reconsidering 'scene safety'
I understand. We''e been teaching scene safety as an absolute for so long, why wouldn't the EMS safety establishment rise up and declare the idea heresy" Proposing that EMS enter a scene when safety is not an iron clad guarantee flies in the face of everything we've been teaching for darn near half a century. Which is perhaps the best reason to consider it.
Every other public safety discipline has had to embrace the muddy waters of risk-benefit analysis, deciding when the risk is acceptable for the potential lifesaving reward, while EMS has remained clean by dodging the issue entirely. By teaching an absolutist view of scene safety, we dodge the complexities of the proverbial scene safety bullet.
In teaching that we do not enter the scene unless it is completely safe, we offer an oversimplified version of a more complex truth. I've also come to believe that we do our people a disservice. The idea that the scene can be made safe is a myth. And we'd do better to recognize the more complex and uncomfortable truth.
You do a dangerous job
A lot of the pushback from the scene safety absolutists is push back about being forced to do what is perceived as dangerous work. "If you want to do dangerous things," they argue, "go be a cop or a firefighter."
Another observes that, "Nothing matters more than going home to my family at the end of my shift."
I agree that going home to your family is of paramount importance. If it is your first consideration when making life choices, might I suggest that you already signed up for a deceptively dangerous job. Driving a vehicle emergent — red lights and sirens — is dangerous. Working on a freeway at night is remarkably dangerous. Drunk people can be dangerous. Entering homes with little idea of what's happening inside is dangerous.
If you feel like your job is safe and the rescue task force folks are suggesting a much more dangerous version of your job, I'd like to suggest that you're being naive about the dangers of your job. And I genuinely believe that you will be safer by overcoming your naiveté.
Safety is not absolute, it's relative
I cringe when I hear people say, "I don't enter the scene until the scene is safe."
Your safety isn't a light switch that can be turned off and on. If you believe it is, may I offer you a 9mm lesson in scene safety"
The scene is never safe. Even the most benign looking calls can rapidly deteriorate and most of the folks who are injured or die in the line of duty have this in common … they never saw it coming.
When you change your mindset to recognize the complex relative nature of your personal safety, you'll start evaluating your safety on an ongoing basis. When you consider that your initial assessment of the safety of the scene may be incorrect, you'll become more diligent and aware.
You'll also start actively considering the current risk profile of your environment and doing a true risk benefit analysis. You start asking yourself, are the risks currently being incurred by my team worth the benefit of our presence" When you recognize the relative nature of safety, you become safer.
You are already doing risk-benefit analysis
Having the ability to deploy medics into a scene to extract victims during an active killer incident doesn't mean that it becomes the automatic response to the scenario. It will be appropriate in some cases and not in others.
This requires us to think our way through the scene and understand the capabilities and weaknesses of our team. It means we will need to evaluate the threat, consider the unknowns and evaluate the possible gains.
You already do this. When you decide whether or not a drunk or uncooperative patient will be placed in restraints, you do risk-benefit analysis. You also do it every time you decide to turn your back on a patient to grab a blood pressure cuff.
If you sometimes drive a little bit faster en route to a child not breathing or step aside and allow a police officer to go through a door in front of you instead of behind you, you understand how we sometimes assume additional risk or choose a more conservative path.
You're likely doing this to some degree on every call you run. You risk more to save more. You risk less to save less. You decide how fast you drive. You decide what environment you're comfortable entering. You decide when to stay and when to go.
Risk-benefit analysis isn't recklessness
Some folks will tell you that EMS personnel who want to enter a shooting or stabbing scene behind police officers are reckless cowboys looking for a thrill. On the contrary, I think the people advocating for this capability are some of the most risk conscious among us.
When we are risk conscious we see that our risk tolerance can adapt to the needs of the scene. When a car accident in the middle of the freeway appears minor we may wait in our vehicle for additional resources to control traffic. When the car is overturned and people are lying in the road, we may choose to use our vehicle to shield them and attempt to rapidly remove them.
The scene has the same risk profile. But the circumstances warrant a different — perhaps more risky — approach. This isn't reckless, this is a willingness to apply our judgement and decision making capacity to the problem as it presents itself to us in real time. A willingness to work with less than ideal certainty, when the potential for benefit is great, isn't reckless, it's thoughtful, rational and reasonable.
Let's get real about the dangers of EMS
I hope the rescue task force idea takes hold. It could do a lot of good for folks injured inside hostile environments. The next Dave Sanders might be someone you love. Beyond the benefit to this small group of potential patients, it could also do us a lot of good as an industry, by compelling us to stop preaching the easy-road on scene safety.
It could finally force us to recognize that safety is not an absolute, to teach that reasoned risk-benefit analysis is essential and to get real with each other about the dangers of working in emergency services.
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