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EMSWORLD.com | JULY 2016 23 "We'd started receiving these tweets on our fire department Twitter account," says Crews. "It looked like Arabic writing, and then there were pictures of carnage and messages like 'Ha ha ha, we got you, San Bernardino City Fire Deparment!' and things along those lines. We immediately went to homeland security and said, 'Something's going on.' That's when I realized this was a terrorist attack. Before that we didn't know what it was, if it was workplace violence or something else." Authorities responded by sending extra security to all fire sta- tions. The culprit(s) behind the tweets has not been identified, though they came before Farook and Malik were killed. That's the kind of thing that makes you really appreciate some extra protection, and force protection and perimeter control were among the lessons culled from the IRC event. "It could have been very easy," notes Crews, "for the shooters to have obtained an unmarked car and come right back into the scene. CHP was watching the perimeter, but there were so many people coming in and out, and we weren't sure who they were or what their role was. That was one of our biggest concerns." On the whole, though, things went smoothly, due in no small part to the training conducted and relationships developed among fire, EMS, law enforcement and other local players. In 2013, in fact, they'd all conducted an active-shooter drill over three days at a local high school. This prolonged exercise let them try different approaches and tweak details to make their MCI operations more efficient. One of the things they tested during that time was having a tacti- cal medic enter the hot zone and start getting patients to a casualty collection point. Another was moving the triage and treatment area as close to the action as possible (its distance from the wounded created challenges at incidents like Columbine, Aurora and LAX). Both of those strategies were employed at the IRC. The triage/ treatment area was placed by the law enforcement IC at the edge of the hot zone due to its easy access and visibility to the unified command location and casualty collection point. "Training and trying different things is the key," says Crews. "It will make a difference what type of building you're in, what type of city you're in, how many patients there are. So it's important not to just rely on one thing in the toolbox, but to utilize many things." It remains true, if not new, that relationships matter. You don't want to meet your FD/EMS/law enforcement peers for the first time at an evolving mass-casualty scene. "Relationships played a huge role that day," says Molloy. "We trust each other; there was no question about what needed to be done. We pulled up on scene, and my folks fully engaged by sim- ply asking, 'What do you need?' There were so many opportunities for things that could have gone wrong but didn't, and I think it was because we worked so well together and functioned in that capacity that it went as smoothly as it did." Takeaway Points Still, there are always lessons to learn. To the end of force protection, one was potentially using vehicles to shield personnel at the scene. "We're so organized to line up our vehicles," says Crews. "The police just show up on scene and park where they park, which we criticize at times. But what EMS does is pull into that scene and line up in these perfect little clean walls you see in all the pictures. And it looks beautiful, but it doesn't really protect us. So we've talked about using those apparatus as a safety barrier around that treatment area and blocking ourselves a little bit more from the building." There were, as there often still seem to be at complex incidents like this, interoperability issues as well. San Bernardino has its own frequency for police, which isn't interoperable with the CONFIRE (Consolidated Fire Agencies of San Bernardino County) system used by everyone else. TABLE 3: PATIENT TYPE AND SEVERITY Injury Severity Number Death 14 Gunshot wound/critical 11 Gunshot wound/complex 5 Gunshot wound/soft tissue only 4 Orthopedic 8 Total 42 Death—Triaged on scene as dead. Gunshot wound/critical—Patient required emergency surgery. Gunshot wound/complex—Patient had wounds involving multiple systems, e.g., soft tissue with fractures or soft tissue with neurological defcit. Gunshot wound/soft tissue only—Did not require surgical repair or was not accompanied by life-threatening blood loss. Orthopedic—Non-life-threatening wounds not caused by gunshots, e.g., trip and fall.