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6th
International Disaster and Risk Conference IDRC 2016
‘Integrative Risk Management – Towards Resilient Cities‘ • 28 Aug – 1 Sept 2016 • Davos • Switzerland
www.grforum.org
Adapting Mass Casualty Response
in an Era of Increased Active
Shooter Incidents
Brad Keating, MPH, CPH, NRP
Colorado Springs Fire Department
United States of America
6th
International Disaster and Risk Conference IDRC 2016
‘Integrative Risk Management – Towards Resilient Cities‘ • 28 Aug – 1 Sept 2016 • Davos • Switzerland
www.grforum.org
Biographical Info
• Firefighter Paramedic for 11 years
• Tactical Paramedic for 5 years
• International disaster response team leader for 6
years
• Master’s Degree in Public Health in Global Disaster
Management and Humanitarian Relief
6th
International Disaster and Risk Conference IDRC 2016
‘Integrative Risk Management – Towards Resilient Cities‘ • 28 Aug – 1 Sept 2016 • Davos • Switzerland
www.grforum.org
Public Mass Shooting Deaths and Injuries
(2009-2015)
0
100
200
300
400
500
600
700
800
Serbia Norway Belgium France United
States
EU
Total
Fatalities
Non-Fatal Inuries
6th
International Disaster and Risk Conference IDRC 2016
‘Integrative Risk Management – Towards Resilient Cities‘ • 28 Aug – 1 Sept 2016 • Davos • Switzerland
www.grforum.org
Top Three Preventable Causes of Death on the
Battlefield
60%
33%
6%
Extremity
Hemorrhage
Tension
Pneumothorax
Airway Obstruction
6th
International Disaster and Risk Conference IDRC 2016
‘Integrative Risk Management – Towards Resilient Cities‘ • 28 Aug – 1 Sept 2016 • Davos • Switzerland
www.grforum.org
THREAT System for Improving Survivability of
Active Shooter Incidents
• Based on Hartford Consensus:
– Obtained input from medical, law enforcement,
fire/rescue, EMS and military experts
• Threat Suppression
• Hemorrhage Control
• Rapid
Extrication
• Assessment by Medical Providers
• Transport to definitive care
6th
International Disaster and Risk Conference IDRC 2016
‘Integrative Risk Management – Towards Resilient Cities‘ • 28 Aug – 1 Sept 2016 • Davos • Switzerland
www.grforum.org
“The fate of the wounded rests in the
hands of the one who applies the first
dressing.”
– Dr. Nicholas Senn, Founder of
Military Surgeons of the United
States (1897)
6th
International Disaster and Risk Conference IDRC 2016
‘Integrative Risk Management – Towards Resilient Cities‘ • 28 Aug – 1 Sept 2016 • Davos • Switzerland
www.grforum.org
Zone Approach in Active Shooter Situations
Hot Zone
• Portion of scene
with active
engagement of
threat
• Law
enforcement
only
Warm Zone
• No direct threat,
but potential for
harm still exists
• Rapid triage
• Lifesaving
interventions
Cold Zone
• Safe area,
outside of scene
and away from
danger
• Unified
command
• Casualty
collection points
• Evacuation
6th
International Disaster and Risk Conference IDRC 2016
‘Integrative Risk Management – Towards Resilient Cities‘ • 28 Aug – 1 Sept 2016 • Davos • Switzerland
www.grforum.org
Mass Shooter Incident
Shooter
Casualty
6th
International Disaster and Risk Conference IDRC 2016
‘Integrative Risk Management – Towards Resilient Cities‘ • 28 Aug – 1 Sept 2016 • Davos • Switzerland
www.grforum.org
Isolation of Shooter
Law
Enforcement
6th
International Disaster and Risk Conference IDRC 2016
‘Integrative Risk Management – Towards Resilient Cities‘ • 28 Aug – 1 Sept 2016 • Davos • Switzerland
www.grforum.org
Integrated Entry Teams
• Integrated Entry Team
– 3 Law Enforcement
– 2 Medical Providers
• After initial law enforcement responders have made contact
with the threat the first integrated entry teams makes rapid
entry into warm zone to perform triage and life saving
interventions
• Secondary teams make entry to remove victims to a casualty
collection point for evacuation
6th
International Disaster and Risk Conference IDRC 2016
‘Integrative Risk Management – Towards Resilient Cities‘ • 28 Aug – 1 Sept 2016 • Davos • Switzerland
www.grforum.org
2
2
22
2
Primary Integrated Rapid Entry Team
1
1
Law enforcement
EMS
Order of entry1
6th
International Disaster and Risk Conference IDRC 2016
‘Integrative Risk Management – Towards Resilient Cities‘ • 28 Aug – 1 Sept 2016 • Davos • Switzerland
www.grforum.org
3
3
33
3
Secondary Integrated Rapid Entry Team
1
2
2
2
1
2
2
Law enforcement
EMS
Order of entry1
6th
International Disaster and Risk Conference IDRC 2016
‘Integrative Risk Management – Towards Resilient Cities‘ • 28 Aug – 1 Sept 2016 • Davos • Switzerland
www.grforum.org
What to Carry
• Triage Tape
• Life Saving Interventions
– Tourniquets
– Hemostatic Gauze
– Nasopharyngeal Airways
– Chest Decompression Needles (10 gauge, 3 inch)
6th
International Disaster and Risk Conference IDRC 2016
‘Integrative Risk Management – Towards Resilient Cities‘ • 28 Aug – 1 Sept 2016 • Davos • Switzerland
www.grforum.org
Current Triage Methods are Overcomplicated
and Lead to Over- and Under-Triaging
• Currently utilized methods (SALT, START) have only a 55-65% accuracy rate
for appropriate triage (Bhalla, et. al.)
6th
International Disaster and Risk Conference IDRC 2016
‘Integrative Risk Management – Towards Resilient Cities‘ • 28 Aug – 1 Sept 2016 • Davos • Switzerland
www.grforum.org
Proposed Two-Step Triage Model
Casualty without signs
of obvious death
Casualty follows
commands?
Radial pulse
present?
Radial pulse
present?
Delayed Urgent Urgent
Expectant/
Deceased
Yes No
Yes No Yes No
6th
International Disaster and Risk Conference IDRC 2016
‘Integrative Risk Management – Towards Resilient Cities‘ • 28 Aug – 1 Sept 2016 • Davos • Switzerland
www.grforum.org
Integrated Training and Planning
• Be prepared for active shooter events
• All responding agencies operate under a standard
protocol
• Unified command structure
• Delaying entry can lead to an increased mortality
rate for those wounded in the event
6th
International Disaster and Risk Conference IDRC 2016
‘Integrative Risk Management – Towards Resilient Cities‘ • 28 Aug – 1 Sept 2016 • Davos • Switzerland
www.grforum.org
The Cost of Delayed Entry
6th
International Disaster and Risk Conference IDRC 2016
‘Integrative Risk Management – Towards Resilient Cities‘ • 28 Aug – 1 Sept 2016 • Davos • Switzerland
www.grforum.org
Concluding Remarks
• Active shooter incidents are becoming a more
frequent reality in the current geopolitical
environment
• Preparation is the key to a unified and effective
response
• Deficiencies in responses can lead to an increased
mortality rate for victims
• A more efficient triage and treatment system is
needed for mass trauma situations
6th
International Disaster and Risk Conference IDRC 2016
‘Integrative Risk Management – Towards Resilient Cities‘ • 28 Aug – 1 Sept 2016 • Davos • Switzerland
www.grforum.org
Questions?
6th
International Disaster and Risk Conference IDRC 2016
‘Integrative Risk Management – Towards Resilient Cities‘ • 28 Aug – 1 Sept 2016 • Davos • Switzerland
www.grforum.org
References
• http://crimeresearch.org/2015/06/comparing-death-rates-from-
mass-public-shootings-in-the-us-and-europe/
• https://www.narescue.com/media/custom/upload/File-
1444161077.pdf
• http://www.naemt.org/Files/LEFRTCC/Hartford_Consensus.pdf
• http://www.pffnh.org/docs/Bureau%20of%20EMS%20Active%20Sh
ooter%20Best%20Practices%20Guide.pdf
• http://www.naemt.org/
• Bhalla, M., Frey, J., Rider, C., Nord, M., & Hegerhorst M. (2015).
Simple triage algorithm and rapid treatment and sort, assess,
lifesaving interventions, treatment, and transportation mass
casualty triage methods for sensitivity, specificity, and predictive
values. American Journal of Emergency Medicine, 33(11), 1687-91.
Doi: 10.1016/j.ajem.2015.08.021
• http://www.cnn.com/2016/06/12/us/orlando-nightclub-shooting/

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Adapting Mass Casualty Response In An Era Of Increased Active Shooter Incidents, Bradley KEATING

  • 1. 6th International Disaster and Risk Conference IDRC 2016 ‘Integrative Risk Management – Towards Resilient Cities‘ • 28 Aug – 1 Sept 2016 • Davos • Switzerland www.grforum.org Adapting Mass Casualty Response in an Era of Increased Active Shooter Incidents Brad Keating, MPH, CPH, NRP Colorado Springs Fire Department United States of America
  • 2. 6th International Disaster and Risk Conference IDRC 2016 ‘Integrative Risk Management – Towards Resilient Cities‘ • 28 Aug – 1 Sept 2016 • Davos • Switzerland www.grforum.org Biographical Info • Firefighter Paramedic for 11 years • Tactical Paramedic for 5 years • International disaster response team leader for 6 years • Master’s Degree in Public Health in Global Disaster Management and Humanitarian Relief
  • 3. 6th International Disaster and Risk Conference IDRC 2016 ‘Integrative Risk Management – Towards Resilient Cities‘ • 28 Aug – 1 Sept 2016 • Davos • Switzerland www.grforum.org Public Mass Shooting Deaths and Injuries (2009-2015) 0 100 200 300 400 500 600 700 800 Serbia Norway Belgium France United States EU Total Fatalities Non-Fatal Inuries
  • 4. 6th International Disaster and Risk Conference IDRC 2016 ‘Integrative Risk Management – Towards Resilient Cities‘ • 28 Aug – 1 Sept 2016 • Davos • Switzerland www.grforum.org Top Three Preventable Causes of Death on the Battlefield 60% 33% 6% Extremity Hemorrhage Tension Pneumothorax Airway Obstruction
  • 5. 6th International Disaster and Risk Conference IDRC 2016 ‘Integrative Risk Management – Towards Resilient Cities‘ • 28 Aug – 1 Sept 2016 • Davos • Switzerland www.grforum.org THREAT System for Improving Survivability of Active Shooter Incidents • Based on Hartford Consensus: – Obtained input from medical, law enforcement, fire/rescue, EMS and military experts • Threat Suppression • Hemorrhage Control • Rapid Extrication • Assessment by Medical Providers • Transport to definitive care
  • 6. 6th International Disaster and Risk Conference IDRC 2016 ‘Integrative Risk Management – Towards Resilient Cities‘ • 28 Aug – 1 Sept 2016 • Davos • Switzerland www.grforum.org “The fate of the wounded rests in the hands of the one who applies the first dressing.” – Dr. Nicholas Senn, Founder of Military Surgeons of the United States (1897)
  • 7. 6th International Disaster and Risk Conference IDRC 2016 ‘Integrative Risk Management – Towards Resilient Cities‘ • 28 Aug – 1 Sept 2016 • Davos • Switzerland www.grforum.org Zone Approach in Active Shooter Situations Hot Zone • Portion of scene with active engagement of threat • Law enforcement only Warm Zone • No direct threat, but potential for harm still exists • Rapid triage • Lifesaving interventions Cold Zone • Safe area, outside of scene and away from danger • Unified command • Casualty collection points • Evacuation
  • 8. 6th International Disaster and Risk Conference IDRC 2016 ‘Integrative Risk Management – Towards Resilient Cities‘ • 28 Aug – 1 Sept 2016 • Davos • Switzerland www.grforum.org Mass Shooter Incident Shooter Casualty
  • 9. 6th International Disaster and Risk Conference IDRC 2016 ‘Integrative Risk Management – Towards Resilient Cities‘ • 28 Aug – 1 Sept 2016 • Davos • Switzerland www.grforum.org Isolation of Shooter Law Enforcement
  • 10. 6th International Disaster and Risk Conference IDRC 2016 ‘Integrative Risk Management – Towards Resilient Cities‘ • 28 Aug – 1 Sept 2016 • Davos • Switzerland www.grforum.org Integrated Entry Teams • Integrated Entry Team – 3 Law Enforcement – 2 Medical Providers • After initial law enforcement responders have made contact with the threat the first integrated entry teams makes rapid entry into warm zone to perform triage and life saving interventions • Secondary teams make entry to remove victims to a casualty collection point for evacuation
  • 11. 6th International Disaster and Risk Conference IDRC 2016 ‘Integrative Risk Management – Towards Resilient Cities‘ • 28 Aug – 1 Sept 2016 • Davos • Switzerland www.grforum.org 2 2 22 2 Primary Integrated Rapid Entry Team 1 1 Law enforcement EMS Order of entry1
  • 12. 6th International Disaster and Risk Conference IDRC 2016 ‘Integrative Risk Management – Towards Resilient Cities‘ • 28 Aug – 1 Sept 2016 • Davos • Switzerland www.grforum.org 3 3 33 3 Secondary Integrated Rapid Entry Team 1 2 2 2 1 2 2 Law enforcement EMS Order of entry1
  • 13. 6th International Disaster and Risk Conference IDRC 2016 ‘Integrative Risk Management – Towards Resilient Cities‘ • 28 Aug – 1 Sept 2016 • Davos • Switzerland www.grforum.org What to Carry • Triage Tape • Life Saving Interventions – Tourniquets – Hemostatic Gauze – Nasopharyngeal Airways – Chest Decompression Needles (10 gauge, 3 inch)
  • 14. 6th International Disaster and Risk Conference IDRC 2016 ‘Integrative Risk Management – Towards Resilient Cities‘ • 28 Aug – 1 Sept 2016 • Davos • Switzerland www.grforum.org Current Triage Methods are Overcomplicated and Lead to Over- and Under-Triaging • Currently utilized methods (SALT, START) have only a 55-65% accuracy rate for appropriate triage (Bhalla, et. al.)
  • 15. 6th International Disaster and Risk Conference IDRC 2016 ‘Integrative Risk Management – Towards Resilient Cities‘ • 28 Aug – 1 Sept 2016 • Davos • Switzerland www.grforum.org Proposed Two-Step Triage Model Casualty without signs of obvious death Casualty follows commands? Radial pulse present? Radial pulse present? Delayed Urgent Urgent Expectant/ Deceased Yes No Yes No Yes No
  • 16. 6th International Disaster and Risk Conference IDRC 2016 ‘Integrative Risk Management – Towards Resilient Cities‘ • 28 Aug – 1 Sept 2016 • Davos • Switzerland www.grforum.org Integrated Training and Planning • Be prepared for active shooter events • All responding agencies operate under a standard protocol • Unified command structure • Delaying entry can lead to an increased mortality rate for those wounded in the event
  • 17. 6th International Disaster and Risk Conference IDRC 2016 ‘Integrative Risk Management – Towards Resilient Cities‘ • 28 Aug – 1 Sept 2016 • Davos • Switzerland www.grforum.org The Cost of Delayed Entry
  • 18. 6th International Disaster and Risk Conference IDRC 2016 ‘Integrative Risk Management – Towards Resilient Cities‘ • 28 Aug – 1 Sept 2016 • Davos • Switzerland www.grforum.org Concluding Remarks • Active shooter incidents are becoming a more frequent reality in the current geopolitical environment • Preparation is the key to a unified and effective response • Deficiencies in responses can lead to an increased mortality rate for victims • A more efficient triage and treatment system is needed for mass trauma situations
  • 19. 6th International Disaster and Risk Conference IDRC 2016 ‘Integrative Risk Management – Towards Resilient Cities‘ • 28 Aug – 1 Sept 2016 • Davos • Switzerland www.grforum.org Questions?
  • 20. 6th International Disaster and Risk Conference IDRC 2016 ‘Integrative Risk Management – Towards Resilient Cities‘ • 28 Aug – 1 Sept 2016 • Davos • Switzerland www.grforum.org References • http://crimeresearch.org/2015/06/comparing-death-rates-from- mass-public-shootings-in-the-us-and-europe/ • https://www.narescue.com/media/custom/upload/File- 1444161077.pdf • http://www.naemt.org/Files/LEFRTCC/Hartford_Consensus.pdf • http://www.pffnh.org/docs/Bureau%20of%20EMS%20Active%20Sh ooter%20Best%20Practices%20Guide.pdf • http://www.naemt.org/ • Bhalla, M., Frey, J., Rider, C., Nord, M., & Hegerhorst M. (2015). Simple triage algorithm and rapid treatment and sort, assess, lifesaving interventions, treatment, and transportation mass casualty triage methods for sensitivity, specificity, and predictive values. American Journal of Emergency Medicine, 33(11), 1687-91. Doi: 10.1016/j.ajem.2015.08.021 • http://www.cnn.com/2016/06/12/us/orlando-nightclub-shooting/