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CASE REVIEW By James J. Augustine, MD, FACEP 12 MARCH 2015 | EMSWORLD.com ABOUT THE AUTHOR James J. Augustine, MD, FACEP, is an emergency physician and the director of clinical operations at EMP in Canton, OH. He serves on the clinical faculty in the Department of Emergency Medicine at Wright State University; as an EMS medical director for fire-based systems in Atlanta, GA; Naples, FL; and Dayton, OH; and on the EMS World Editorial Advisory Board. Contact him at jaugustine@emp.com. THE MORNING IS QUIET. Station duties, and a quick training exercise on the use of the new textile devices that can be used to move large persons, are completed. The urgency of the dispatcher's voice is evident from the first syllables. Officer down, active shooting event, Signal 99 for law enforcement. County courthouse, stage away from the scene. Attack One respond. The Attack One officer processes the words in her head, and silently recites in her mind, "This is not a drill." Understanding the communications center will be completely committed to law enforcement activity, the battalion chief takes responsibility for immedi- ately calling for three additional paramedic units, establishing a staging point three blocks from the courthouse for all fire and EMS units, and designating a tactical channel for all fire-EMS communications regarding the incident. A second battalion chief will respond as the safety officer, and a ladder truck will be dispatched to serve initially as staging command. Before they can arrive at the staging area, Attack One is routed into the scene at the request of the ranking law enforcement officer (LEO) on the scene, who makes the request directly on the EMS radio channel. The battalion chief asks the officer if the scene is safe for entry, and the LEO reports, "No sir, but we have an officer down on the street north of the courthouse with severe injuries." The battalion chief confirms the communication with the LEO, and makes sure the Attack One crew understands they will be the only unit entering the area, and to take all necessary precautions to protect themselves while scooping and removing any victim as rapidly as possible. The Attack One crew leader sets the priorities immediately for the three-person crew. "Don your helmet and your turnout jacket. The only equipment on us will be tourniquets, a bag of trauma dressings, our trauma scissors and one of those tex- tile devices we just trained on. We will pull up to a protected area half a block away, run to the scene with those rescue items only, and plan to grab the victim and carry him or her back to some protected area near the vehicle. No delays allowed." Officer Down EMS operations at an active shooter incident require careful coordination with law enforcement The paramedic places a rapid call to the medical direction phone at the trauma center, which is close to the scene. "Please place yourself on alert status. We have no details, but are responding to an active shooter scene with the report of one serious injury and an ongoing event at the courthouse. Monitor traffic and we will get you any patient details if we can." Attack One approaches and finds three officers, with guns drawn, protecting an officer who is prone on the sidewalk. There is blood visible on the ground as they run in with their streamlined equipment. The officers give a rapid report that at least one individual was shooting inside the courthouse where there are more casualties. This officer was not on duty yet, so was not protected by body armor. As he walked toward the courthouse, the shooter bolted out of a door and shot the officer without warning. The crimi- nal continued to run, but they do not have a direction or a good description of the criminal. This officer has been unconscious since the other officers arrived. They note the officer was shot in the upper abdo- men and in the face. He is not responsive to verbal directions, and his airway and breathing are com- promised. The paramedic proceeds quickly to load the officer onto the textile sheet. A trauma dressing is placed over the abdominal wound, and one over the facial wound. The LEOs are advised that the injured officer will be carried half a block away, where they will ren- dezvous with a transport ambulance, and the officer will be transported immediately to the trauma center. Copyright granted for this ar ticle for depar tment use only up to 20 copies. Photo by Lynn Levit t