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CASE REVIEW | By James J. Augustine, MD, FACEP The Gravity of the Situation A standoff with a killer 350 feet in the air has big implications for EMS ATTACK ONE RESPONDS to a report of a police standby. This call began with an unruly customer in a local bar and grill, and just as offi cers arrived, the man ran from the establishment and climbed up a 35-story crane at a building site next door. The police have asked for EMS assistance as they prepare for a standoff. The Attack One crew receives a rapid briefi ng. The man is a murderer who escaped from custody in another state, stole a car and drove to this city. He entered the restaurant, where he ate a meal, drank a signifi cant quantity of alcohol and then ran out to the adjacent construction site. That is the site of a future skyscraper, with about 15 fl oors already in steel and concrete. The crane serving the site has a horizontal arm about 200 feet above that, or about 350 feet off the ground. It is not being used at this time. The man climbed all the way up the vertical element of the crane, being chased by two police offi cers. Once at the top, he pulled up a segment of the ladder so he could not be reached directly. Copyright granted for this article for department use only up to 20 copies. After reaching the top, the man became very hostile, breaking off pieces of the crane and throwing them at the offi cers on the lower part of the ladder and persons on the busy street below. Unfortunately, when the crane operator had fi nished work the day before, he’d left the crane’s horizontal arm extended out over the street, allowing the man to drop or throw objects (now including his own waste) on the cars and pedestrians beneath. So the street was shut down, the special opera- tions law enforcement team activated, and the crane left inoperable. As the law enforcement operation ramped up, EMS was called for the safety of law enforcement, bystanders and the hostile man. The Attack One crew member in charge listens to the original briefi ng, meets the law enforcement senior 28 JULY 2011 | EMSWORLD.com offi cer in command, and notifi es the on-duty fi re chief to report to the scene. Within an hour, the lead members of the police department and fi re-EMS at the site conduct an incident manage- ment meeting and start planning a prolonged operation. The man has been increasingly aggressive, moving around, breaking pieces and threat- ening offi cers and the crowd that has gathered below. His criminal record indicates he is dangerous, and his current behavior gives every indica- tion he will not cooperate for any rapid resolution of the incident. The initial incident manage- ment meeting results in creation of an incident action plan (IAP) based on a model developed and used daily by the fi re-EMS agency. Origi- nally in handwritten form, it outlines the initial critical elements of the incident. A Planning Section will be created and empowered to develop a detailed plan over the next 12 hours. In the meantime, the initial plan briefl y outlines these elements: Law enforcement is in charge of the operation, with an on-scene police major designated as Incident Commander. Leadership will change only if the man fi nds a way to access the crane operator’s booth and use the crane as a weapon or set it on fi re— that would create a life-safety hazard, at which point the senior fi re-EMS offi cer would temporarily take charge of the operation. Otherwise law enforcement is in charge of the operation and inves- tigation, and will be assisted by federal law enforcement agents who have now arrived at the scene. From the beginning, the major feels this will be a prolonged incident. Based on his experience with determined and desperate criminals in the past, he prepares his forces for an operation lasting three or more days. He suggests fi re-EMS set up for a similar duration. He designates three important elements INITIAL ASSESSMENT A 32-year-old male in no distress. His only complaint is extreme thirst and irritation of his legs from an electronic stun gun. ❯ Airway: Patent. ❯ Breathing: No respiratory distress. ❯ Circulation: Brisk capillary refi ll. ❯ Disability: No compromise. ❯ Exposure of Other Major Problems: The patient is tachycardic and will have to be secured for a 350-foot trip in a rescue basket to the ground. VITAL SIGNS Time HR RR Pulse Oximetry 2305 140 28 98% on R. index fi nger 2315 128 24 99% 2347 120 18 99% SECONDARY ASSESSMENT (ON ARRIVAL OF PATIENT TO GROUND) No injury noted. Barbs from the stun gun have caused minor irritation to the upper legs. The man complains only of thirst. He is mildly uncooperative. AMPLE ASSESSMENT ❯ Allergies: None. ❯ Medications: None. ❯ Past Medical History: No signifi cant medical problems. ❯ Last Intake: Hasn’t eaten for 5 days. ❯ Event: Person who survived for fi ve days in a standoff with police on the top surface of a crane, 350 feet off the ground. of the law enforcement operation, to rotate on a staggered basis. He will rotate his law enforcement command staff and PIO in 12-hour shifts; his highly trained SWAT members, who will be up on the crane, in 8-hour shifts; and regular uniformed offi cers on normal 6-hour shifts to provide perimeter control. Investigation staff will be kept on call and summoned only if the incident appears to be coming to resolution. The Planning Section is asked to address contingencies: What is worst that could happen? What will improve