DHS Office of Health Affairs

• 73 pages
• June 2015

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

1. 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).

2. 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

1. 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.

2. 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.

3. 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

1. 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.

2. Local and state emergency management, EMS, fire, and law enforcement personnel and receiving medical facilities should have interoperable radio and communications equipment.

3. 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.

4. Training to improve first responder triaging precision is essential for dealing with IED and/or active shooter incidents.

5. 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.

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Threat-Based Scenarios

This section includes a list of scenarios and recommended medical and planning considerations. As the end-users of these scenarios, first responders are encouraged to incorporate details relevant to their local landmarks, response procedures, and practices. The purpose of the following scenarios is to guide first responder education and training efforts toward incorporation and institutionalization of the previous responder guidelines in a variety of likely IED and/or active shooter situations. These scenarios can be used individually as stand-alone resources, or they can be used in conjunction with the other scenarios provided. They are intended to be used for collaborative planning, training, and exercises with EMS, fire, and law enforcement resources together. Ideally, role playing should be done to help first responders better understand each other’s processes and roles and the importance of unified command and interoperability.

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Scenario 1: Large-Scale Terrorist/Insurgency Attack

Large-scale attack using an IED with over 100 pounds net explosive weight, producing mass casualties with the likelihood of overwhelming the response and receiving infrastructure. This scenario may include vehicle-borne improvised explosive devices (VBIEDs).

EXAMPLE: You are called to the scene of a reported explosion at a train station (or other public location). Initial reports indicate that a truck drove around barriers and into the entrance of the facility and then detonated. 911 callers indicate that there are several dead and many others with multiple injuries—some extremely serious. You are the first arriving unit on the scene…

Expected Injury Patterns

For those who survive this event, injuries can include multiple amputees with pelvic/perineal components, penetrating thoraco-abdominal injuries, pulmonary contusions from closed space blasts, burns, TBI, including penetrating head injury, and neck trauma. While primary blast injuries can occur from both open space (e.g., roadside IED) and closed space (e.g., buildings, trains, and buses) bombings, it is especially common after closed space bombings.

Protective Equipment and Barriers

Secondary preventive measures include activities to prevent injuries once an explosion has occurred. Such measures may include barrier or structural walls that may protect or reduce injuries to bystanders and responders from blast and fragmentation injuries.xxi Secondary preventive measures also include use of ballistic protective equipment, although soft body armor and ceramic plate body armor may not protect against fragmentation or blast overpressure effects from IEDs. Most protective equipment is focused on ballistic protection and may have unproven or limited value for mitigating fragmentation or blast overpressure, particularly for devices with larger net explosive weights, such as vehicle bombs. For protective equipment and barriers to be effective, they must be implemented proactively; they are of little use when the explosive event is random and enacted on an unsuspecting, unprotected group of individuals. Ballistic protective equipment will also give some level of protection should an IED attack be combined with an active shooter event. Experience indicates attackers may plan to detonate secondary or subsequent IEDs that target first responders or receiving hospitals.

First responders should consider wearing some level of ballistic protective equipment. Considerations for first responder ballistic protective equipment should include what type of equipment is best suited for EMS and fire responders and when it should be worn (every shift, during times of high risk [e.g., on duty at a sports stadium], or just in response to IED events). It is critical that incident commanders base protective equipment and tactical movement guidance at the incident scene on a situational assessment of the IED risk, particularly when IEDs with significant net explosive weight are suspected or confirmed to be present. These types of IEDs, including vehicle bombs, may produce blast overpressure effects that would not be mitigated by typical protective equipment or available cover. A false sense of security among first responders could result if net explosive weight is not considered when determining protective equipment or tactical movement guidance to responders.

Protective Equipment Commonly Worn

Most law enforcement officers responding to the incident will be wearing Type II or IIIA bullet resistant vests, designed to stop bullets from most handguns, and shotgun pellets. Given the expected injuries, this level of protective equipment may not provide protection from blast overpressure and fragmentation, and extremities will be vulnerable. First responders other than law enforcement typically do not wear ballistic protective equipment. Civilians at public places will not be wearing any form of ballistic protective equipment.

Protective Equipment Risk Mitigation Considerations

The NIJ body armor standard specifies the ballistic threats that body armor must reliably protect against. This standard does not specify a requirement for ballistic resistant vests to protect against fragmentation threats. The Type II or IIIA ballistic resistant vests that law enforcement officers are most commonly issued will likely not protect against fragmentation and blast overpressure effects from an IED threat. Use of Type IV body armor may increase the probability of protection against fragmentation and blast overpressure. However, further research and development is required to validate the performance of NIJ-approved body armor against fragmentation threats and to provide guidance on what level of protection should be worn to respond to this type of IED event.

Response and Incident Management Considerations

Maximize interoperability through existing MOUs/MOAs/SOPs, as well as through frequent exercises, planning, and training. These efforts will ultimately aid in reducing time from injury to treatment. During response, and while on the scene of the incident, use unified command with a mutual understanding of each responder’s role (EMS, fire, and law enforcement). Strive to communicate on common frequencies and use standardized terminology. Ensure all responders (regardless of discipline—EMS, fire, and law enforcement) are trained and equipped to provide early, aggressive hemorrhage control; use protective equipment (which includes ballistic vests, helmets, and eyewear); and use integrated response and incident management.

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