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ACTIVE-SHOOTER RESPONSE medical team must balance the urge to carry everything, which may inhibit a fast, flexible and effective response versus a smaller medical kit to deal with trauma only. Training and exercises will help determine the best course of action regarding medical kits. Training events like Urban Shield (www.urbanshield.org) stress the impor- tance of EMS and law enforcement inte- gration. Urban Shield, sponsored and organized by the Alameda (CA) County Sheriff’s Department, is an annual exer- cise that is scenario-based and includes up to 30 checkpoints that SWAT teams rotate through continuously over 48 committed to duplicating the concept and customizing many of the scenarios to address the local needs, critical infra- structure and vulnerabilities of their particular location. Currently, Boston (see www.bostonurbanshield.org for more information), Seattle and Denver are in various states of planning for similar events. EMS integration is a critical component of all of these venues. The Active-Shooter Response Law enforcement takes an aggres- Law enforcement officers provide protective cover for EMS in a “warm zone” active shooter scenario. Law enforcement and EMS can work well together, especially if they train together in events such as Urban Shield. hours. Some of the scenarios include an EMS, MCI, WMD, hazmat or other focus where respective agencies and disciplines integrate with the competing SWAT teams for a more realistic training platform. Funding is provided through various sources, with the Urban Area Security Initiative (UASI) as the primary financial supporter. The continued success of Urban Shield has other cities and countries 48 JULY 2011 | EMSWORLD.com sive approach to an active-shooter incident. When local police realize they can no longer wait for the SWAT team, the current standard and widely accepted approach is to immediately go toward the crisis site/shooter with whatever resources are on hand. Even if there are one, two or three dispa- rate law enforcement officers (for instance, an off-duty officer dropping a child off at school, an armed security officer and a local officer), they make a quick plan, call for backup and go to the sound of shots fired, looking to engage, distract and hope- fully neutralize the threat. In the meantime, other forces begin to muster and stage outside. This includes a variety of law enforce- ment, fire department and other EMS assets. Ideally, a quick command post that embraces the concept of “unified command” is set up. This should include law enforcement, fire, EMS and an agency representative who is familiar with the inner workings, layout and procedures of the facility/ workplace. EMS should have a “light, lean and ready” squad of mixed EMS professionals who are forward-leaning and have good communication with the unified command. Law enforcement should have a protective detail identified and tasked with escorting EMS personnel. Prior to EMS entry, law enforcement should brief EMS about the “do’s and don’ts,” chain of command, emergency egress, room entries and communica- tion. The EMS crew should be prepared to split up if necessary. The exact number and ratio of law enforcement and EMS personnel need to be thought out by each agency and adjusted during training opportunities. The nature of the event, available resources and other factors will dictate the exact ratio and numbers as appropriate. A recom- mended starting place for training is for four EMS providers and at least four law enforcement officers to make up the EMS response team. Conclusion Active-shooter incidents rarely go from hot zone to cold zone quickly. Law enforcement officers know it is their responsibility to get into the crisis site quickly to distract, engage and hope- fully eliminate the threat. EMS, on the other hand, is still waiting for the “all clear” and may be staged for minutes or hours, not willing, able or allowed to get in and start saving lives. Both EMS and law enforcement need to come together, train together and work together to better respond to these inevitable unfortunate incidents. We all know that bleeding eventually stops. Our job in EMS is to provide aggressive, safe and effective medical care while the patient is salvage- able. For more information, e-mail jim. morrissey@acgov.org. REFERENCES 1. Fletcher W. Responding to active shooter incidents. Fire Engineering, January 2011. 2. Sheriff’s Offi ce Policy and Procedure Manual, Chapter &. El Paso County Sheriff’s Offi ce. 2004-01-01. http://shr2. elpasoco.com/PDF/policy/chapter_07/731_policy.pdf. 3. Iselin B, Smith R. www.jems.com/article/major-incidents/ arlington-county-va-task-force. 4. Associated Press. Shoot fi rst: Columbine tragedy transformed police tactics. USA Today, April 19, 2009. www.usatoday.com/news/nation/2009-04-19-columbine- police-tactics_N.htm. 5. Armellino R. Revisiting the Amish schoolhouse massacre. PoliceOne.com News, August 22, 2007. www.policeone.com/pc_print.asp?vid=1290372. Jim Morrissey, MA, EMT-P, is the disaster and terrorism preparedness coordinator for Alameda County (CA) EMS. He is a tactical paramedic for the San Francisco FBI SWAT team and a medical intelligence offi cer for the Northern California Regional Intelligence Center. He holds a master’s degree in homeland se- curity from the Naval Postgraduate School located in Monterey, CA.