Picking up on and quickly disseminating the lessons learned from the emergency responses in Dallas, Orlando, and in places that responded to mass-shooting events is just part of the mission of the new High Threat Task Force assembled by the American College of Emergency Physicians (ACEP). The panel also is aiming to “drive the research agenda to provide evidence for responsible public policy, training, and operational response decision-making,” explains David Callaway, MD, the co-chairman of the task force and director of operational and disaster medicine at Carolinas Medical Center in Charlotte, NC.
“For the past 10 years or so, we have seen this increasing frequency and complexity of domestic attacks and trauma, and emergency medicine physicians have been on the front lines for every one of them, whether that is as EMS medical directors, at community hospitals as first receivers, at trauma centers, or even at the public policy level with different professional organizations,” Callaway says. “Emergency medicine providers have been leading the charge in how we train and how we respond, but the efforts have been disparate.”
Consequently, the task force is hoping to unify all these efforts, iron out any inconsistencies, and provide a stronger national platform, Callaway explains. Further, the panel aims to create “a comprehensive strategy for ACEP to address trauma care from the point of injury through definitive care in high-threat emergencies to eliminate potentially preventable mortality,” he says.
While the idea for the task force was introduced in November 2015, work shifted into high gear immediately after the mass shooting in Orlando, FL, on June 12.
“The key thing is that we have gotten broad stakeholder buy-in for this concept that there is something different about how we provide care in these dynamic active-threat environments, and that the threat actually impacts what we do and when we do it,” Callaway says. “That buy-in has been the biggest key step because [stakeholders] have appointed respected leaders from their organizations [to the panel]. That gives the task force the political capital to move forward with some of our agenda items.”
Establish a Databank, Guidelines
In the short term, Callaway explains that the task force intends to create a structure for rapidly acquiring, analyzing, and disseminating lessons learned after each of these mass-shooting events. Further, the panel hopes to use the public interest in these matters to address what Callaway calls one of the biggest gaps: the lack of evidence-based guidelines for how emergency personnel respond to these events.
“The biggest problem we have right now is that we don’t have a preventable death analysis of these events,” Callaway says. “The military realized this in 2003 and set up the joint trauma system, so when someone is wounded in combat and they make it to a hospital, [he or she] is entered in the joint system and then all the interventions that are done are tracked as well as what the injuries were and whether the patient survived ... so [the military] can basically see who survives and who does not and why. And we have not done that in a civilian setting for these events.”
Given that a national trauma databank already exists with this type of data, physically assembling such a database does not pose much of a challenge, according to Callaway. However, he notes there still are barriers related to the litigation and prosecution of these events at the state level.
“States have different laws about who can access autopsy data, and this significantly restricts the ability to know what type of interventions we should train people in,” Callaway observes. “So one of the first things that will come out of the task force is a joint call-to-action to establish this databank, and to perform a preventable death analysis so we can really understand what is going on and provide good advice to [make] public policy, perform equipment purchases, and to conduct training, education, and operations nationwide.”
Put Added Focus on Situational Awareness
While the incident command system is an important structure, Callaway observes that the system originally was designed to fight wildfires, not events that last five to 22 minutes.
“The average active shooter event lasts about 12 minutes, so it is nearly impossible to stand up an incident command and have it functional in that amount of time,” he explains. “These events require much more of a dynamic leadership response.”
Callaway makes clear that he is not suggesting replacing the incident command structure. In fact, he emphasizes that all emergency personnel must be trained in incident command procedures. However, he asserts that they also must understand when and why they need to stray from those procedures at times.
“We saw this in Aurora, CO [on July 20, 2012] when law enforcement realized that the ambulances couldn’t get into the theater [where a mass shooting had occurred] because there were so many people, so law enforcement transported 75% of the first casualties in the first 30 minutes,” Callaway says, noting that the same thing happened in the aftermath of the mass shooting in Orlando. “They had the situational awareness to realize they were only three blocks from Orlando Regional Medical Center, and so law enforcement literally put people in the backs of pickup trucks and drove them to the trauma center.”
Such a response undoubtedly saved lives, but it would not have been appropriate if the medical center had been a 40-minute drive away, Callaway notes.
“It is really hard to create these rigid response protocols that say cops should always transport people or cops should never transport people,” he notes. “These events cross over between operational decisions and medical decisions, and they require the integration of medical and non-medical personnel at a level and at a speed unlike any other event.”
Develop New Strategies for Training, Mitigating Risk
The ultimate goal of the task force is zero preventable deaths, Callaway says.
However, to get there he stresses that people must understand that the current standard of a no-risk environment no longer exists.
“It is not politically or morally acceptable to have someone die in a cafeteria after a shooter has been killed because you are scared about IEDs [improvised explosive devices]. It is completely, operationally reasonable to be concerned about those IEDs, and you have to be concerned, but it is not acceptable to delay action and to not get the casualties out fast,” he explains. “In these [mass-shooting] events, you have to assume more risks, and so from our standpoint, if we are going to ask people to assume more risk, we have to give them strategies for how to mitigate the risk.”
To accomplish the twin goals of mitigating risk and having zero potentially preventable deaths, the task force will be focusing a lot of time and energy on training and operations.
“Hospitals are always wary to ‘disrupt’ daily operations to prepare for a crisis. This needs to change,” Callaway argues.
What also must change, according to Callaway, is the propensity by governmental organizations to provide funding for gear and equipment, but not so much for training.
“It is much easier to provide quantitative data on the number of ballistic vests provided than it is to show evidence of impact from training police, EMS, fire, and hospitals in terrorism response,” he says. “Risk can be mitigated with a whole community approach to the response. If all responders are trained in the same system with the same language and the same operational parameters, they operate as a living network and are able to be empowered decision makers.”
Establish Best Methods for Data Collection
With many different community pieces involved, why should emergency medicine be the main driver for improvement?
“The vast bulk of prehospital medicine is [overseen] by emergency medicine physicians, but then our day-to-day job is to be that bridge between the community and the prehospital environment and the hospital,” Callaway says. “Many of the physicians who are on the task force have been involved in some of these events over the years, from Virginia Tech to Sandy Hook, and some [have] military [experience] as well.”
The task force already has begun discussions with clinicians who were involved in the emergency responses to the most recent shootings in Orlando and Dallas.
The task force wants to hear about the lessons learned at these events, but Callaway stresses that the panel also wants to figure out the best way to gather this information.
“Our goal is to, in a rapid and sensitive fashion, understand what happened and understand what could have been done better so that we can educate — not for retribution,” he stresses. “Then we need to make sure we get the information out to the rest of our providers because we know that we are seeing an escalation in these events, and shorter times between events.”In one way, the country has been fortunate in that most of these mass-shooting events have occurred in urban areas where emergency resources are close at hand, but Callaway emphasizes that preparation is critical.
“Luck has been on our side, but the more prepared you are, the luckier you get,” he says. “We need to take every one of these events that has happened, and the key is to look at them and pretend that they happened in your city. We need to wargame these events and then wargame the worst-case scenarios.”
SOURCE
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David Callaway, MD, Co-chairman, High Threat Task Force, American College of Emergency Physicians; Director of Operational and Disaster Medicine, Carolinas Medical Center, Charlotte, NC. Email: [email protected].
The Importance of Emergency Preparedness
While national organizations and policymakers study what they can do to improve the response to mass-casualty events, hospitals around the country are scrambling to integrate the latest expert advice from these events into their operations, but it’s a continuing challenge, observes Karen Doyle, MBA, MS, BSN, senior vice president of nursing and operations in the R Adams Cowley Shock Trauma Center at the University of Maryland Medical Center (UMMC) in Baltimore.
“Hospitals get little to no funding for preparedness, so conversations certainly should occur, and we do conduct mass-casualty exercises,” Doyle notes. “We conduct active shooter training through our emergency management committee, we talk about lessons learned, and then we try to incorporate what our colleagues have learned across the nation into those exercises.”
At UMMC, there is a formal process for implementing improvements in the way the hospital prepares for mass-casualty events. “All our plans come through the emergency management committee, which every hospital needs to have according to Joint Commission standards,” Doyle explains. She observes that the catalysts for such changes often come from professional conferences.
“Someone will present a situation, and we will make sure we garner the information from there,” Doyle says. “Then we take that information, whether it is publicized or whether [a member of our staff] has attended the conference, and incorporate it into our disaster [approach] based on what we think we need to bolster in our plans.”
The hospital has not yet had to deal with a mass shooting, but it has dealt with mass-casualty events, and the first order of business is always making sure the resources required to handle the situation are available, Doyle explains. “We had riots in Baltimore ... and we certainly had a lot of patients descend on us,” she explains. “Making sure that you garner your resources, get them to the right place, and that you triage appropriately is first and foremost.”
“Once that aspect is under control, managing the environment outside the hospital requires planning, which can be quite difficult,” Doyle observes. “The press, the people, the rumors, and all the communications that exist — those are things that become very complicated. Delivering care is probably the easiest piece of it.”
As shooting incidents have escalated, UMMC has increased its preparations for this type of event. “We do active shooter training, and we have incorporated escalation techniques into the training of many of our staff,” Doyle notes. “We also have employed a different level of security to monitor the perimeter of our hospital.”
Further, there is a much greater focus on workplace violence at UMMC. The hospital installed panic alarms that employees can use when they feel threatened and hired a security consultant as part of an effort to improve the safety culture. “It’s a huge issue. We have done a lot of work in our institution, and we have a lot more work to do,” Doyle admits. “I don’t feel like we are ever done, but we have a heightened sense of awareness.”
Doyle feels fortunate that she works in a major medical center in a city where resources are plentiful, but she worries about smaller community hospitals. “We can partner with Baltimore City Police and with our rehab centers,” she explains. “Other places that are out there in these rural areas really struggle. Critical access hospitals have very few resources around them.”
