Duane D. Siberski, D.O., FACOEP-D, FACEP, PHP

Media coverage of the latest mass casualty incident [MCI] has decreased.  Parkland High School is in the record book.  Remembrances of previous MCI events tribute the victims ceremoniously.  The Academy of Country Music awards show dedicated to the Route 91 victims, #RunBoston spelled out the city’s name with a course route along the city streets, a Massachusetts’s moment of silence at 2:49 PM occurred five years after the bombing, the National Park located at a plane crash site in Pennsylvania, the corollary New York City memorial and museum with a $44 admission ticket price, an empty field devoid of the removed Amish one room schoolhouse all stand as reminders to previous MCI events.

American public sentiment and awareness ebbs and flows after MCIs occur. The need for an integrated system with well-trained providers responding to mass casualty incidents truly exists.  Critiques of MCIs bring to light shortcomings; communication failure, remote staging of vehicles, incident command without unified command or system integration and more.  Problems identified without definitive monetary support to impact system-wide changes.

The common denominator in all of this is the Emergency Department [ED]. Optimal MCI victim care is a team approach, with challenges ranging from victim transportation, training, logistics, and issues that vary from hospital to hospital.

Education and training in preparation of MCIs exist for first responders and the public. Implementation of programs varies across the country and in each state with many ACOEP members currently involved in these initiatives. Creativity in the implementation of training programs aids in success.

The first question to answer often is when and how do I start?  While not a template for all areas, these are examples of programs and their utilizations.

Programs and Implementations

Run, Hide, Fight

The Office of Homeland Security authored the Run, Hide, Fight video with accompanying information display literature in 2012.  Designed for the workplace, it has been adapted to the school environment with ALICE: Alert-Lockdown-Inform-Counter-Evacuate.  With the video’s emphasis on the three options, it covers the reality of an active shooter event with data pertaining to the random victim choice, short duration and need for heightened awareness.  The training is aimed at maximizing survival during an event in the workplace.  It can be viewed by interested citizens and has been taught by police departments and private entities across the country.

Training for the Berks County Athletic Trainers Association in Pennsylvania used the ALICE curriculum which program brought the need for combined education and scenario-based practice to the forefront.  Utilizing starter pistols, mannequins, and screaming, moulage victims created a chaotic environment for the practice, and providers made decisions to rescue victims, shelter in the locked-down classroom, or evacuate.

Some participants found their response to the active threat became easier with each scenario.  Other athletic trainers had to confront their fear response resulting in freezing in place, unable to make decisions or protect themselves.

Realization of the probability for education site violence is bringing to light the need for training in schools.  There has been a trend toward an attitude of “it can happen here” from the previous ‘it’ll never happen here” lately.  By utilizing the guidelines set forth in the Run, Hide, Fight and ALICE programs, schools can be better prepared.  School administrators, local government, and first responder agencies could be resources to plan such training.

Target Audience: Athletic Trainers – high school and college based

Change: Action plan for improved survivability in education site violence event

Funding: Education budget – Berks County Athletic Trainers Association

Time: 12 hours over past 3 years, 3 training session

Tactical Emergency Casualty Care

Authored by the National Association of Emergency Medical Technicians [NAEMT], the Tactical Emergency Causality Care [TECC] course covers management of trauma victims in austere conditions.  The curriculum teaches rendering care to victims while in direct threat (under attack), indirect threat (when hostile threat is suppressed but can reemerge), and evacuation care (while moving victims from the incident scene).

The military version, Tactical Combat Casualty Care, developed by the U.S. Department of Defense Committee on TCCC, is adapted to battlefield casualties care.  While some TCCC guidelines may not be applicable to civilian application, [e.g. return fire and take cover], the techniques and management are evidence-based for providing life-saving care on the battlefield for victims.

Integrating TECC care into current pre-hospital operations requires accepting the paradigm change from “the scene is safe” to “the scene is as safe as it can be.”  Providers utilize a Rescue Task Force [RTF] model to access victims.  Differing from Tactical EMS or SWAT EMS which proceed with law enforcement into the high-risk area, the Hot Zone, providers of the RTF are escorted, and move as a group with law enforcement to access victims in the lower risk area, the Warm Zone.  Utilizing rapid assessment, techniques to treat limited life-threatening injuries of victims at the point of wounding, while maintaining situational awareness, the RTF moves from victim to victim.

This style of access to victims is a change from operational dogma in EMS.  Cooperative maneuvers with law enforcement in unsecured, but lower threat areas require pre-planning and practice between providers.  Adaptation of more aggressive responses by non-SWAT law enforcement to hostile threats began after 1999 and the Columbine event.   The FBI recognizes this change as life-saving.  While staging EMS at a safe distance, the Cold Zone, is the most common, more EMS agencies are adopting the TECC training and RTF model with local law enforcement.

The Eastern PA Regional EMS Council, Orefield, PA, hosted several TECC courses for providers.  Most recently, a TECC course was grant-funded to provide training for 50 providers on the campus of Penn State Health – St. Joseph Medical Center, Reading, PA.  Participants attended didactic sessions with skills stations practice.  Moulage victims, law enforcement officers for escort, and ballistic protective gear provided the realistic practice during scenario evolutions.

Although TECC training and RTF are not the current standard in Pennsylvania, the Pennsylvania Department of Health-Bureau of EMS currently has the Hostile Threat Work Group. This task force is evaluating the state-wide implementation of a TECC/RTF plan.

Target Audience: Pre-hospital providers – police, fire, EMS

Change: Action plan for pre-hospital providers to decrease preventable deaths in the civilian tactical environment

Funding: Pennsylvania EMS education grant, provider funded

Time: 24 hours TECC, 120 hour Hostile Threat Work Group

Active Shooter Drill

Staging a drill to allow law enforcement, EMS and Fire department personnel allows the practice of techniques for providers involved in the preparation phase of an event.  Pre-planning for such an event can help to minimize and mitigate risk, but not prevent it.  Multi-agency practice drills can help to coordinate each discipline’s roles and responsibilities when responding to an event.  Each program, whether Run, Hide, Fight/ALICE, TECC/TCCC, RTF, or ALERRT: Advanced Law Enforcement Rapid Response Training is designed for the specific groups in response to the same threat.

Scheduling between multiple agencies begins months in advance.  Schools tend to prefer in-service days for staff education events, municipal agencies require needs assessments for budget approvals, instructors, evaluators, Department of Health observers, victims, and food vendors will all need time for scheduling.  Receiving facilities cannot predict activity levels flu season.  Aeromedical units are weather dependent.  The coordination of each entity together resembles a combination of cat wrangling and Jello juggling.

Organizing an active shooter training drill can be a large-scale event when planned to incorporate training programs for a high school, municipal police and fire departments, local EMS agencies, receiving hospital, aeromedical service, instructors, victims, and the news media.  School staff utilize ALICE training, law enforcement divides manpower to the different activities required of contact team or RTF escort team, fire and EMS assemble RTF teams, casualty collection points, triage and transport staging areas, the unified command system maintains communication and incident control with each component seamlessly working together.

Returning to reality, organizing and running multi-agency drills will expose organizational and operational short-comings, system downfalls, unchecked egos of personnel, and heated debates in the hot-wash with associated after-action report for process improvements.  The news media will edit to a favorable 30 second video clip with a short extemporaneous blurb by a drill participant or organizer.  Ultimately, providers will accept the need for improvement and will have had the benefit of skills practice.

Target audience: First responders – law enforcement, fire, EMS, school staff

Change: Action plan and practice in coordinated multi-agency event to minimize and mitigate risk for improved survivability

Funding: Agency dependent ranging from budgeted to donated

Hours: 250 in planning, 10 in drill, 1 hour – confession and penance for lying to parochial high school principal that no participant would be armed [six law enforcement officers as security detail for drill protection were all armed]

Stop the Bleed

In October of 2015, the Office of Homeland Security initiated the Stop the Bleed Campaign.  Intended to “encourage bystanders to become trained, equipped, and empowered to help in a bleeding emergency before professional help arrives,” it addresses treatment at the site of wounding by non-professionals.  With a goal of the lay public providing care to victims prior to the arrival of professional care, as the name implies, it targets uncontrolled hemorrhage.

An EMS outreach program from Penn State Health – St. Joseph Medical Center in Reading, PA brings the Stop the Bleed program to over 110 schools in Berks County kicked off on March 1, 2018.  The program provides a stocked Stop the Bleed box for each school.  Training in the 90-minute program for school staff utilizes ED physicians, nurses and medics and school athletic trainers.  On-going training will be provided at in-services for newly hired staff.  Restocking of the Stop the Bleed box will be done by the hospital in the event there is a need to use the supplies.

Berks County school superintendents embraced the program and although the program’s planning required several months, it was coincidentally implemented shortly after the Parkland event, coincidentally.

Target Audience: School staff

Change: Action plan to provide hemorrhage control prior to professional care arrival

Funding: Hospital advertising budget

Time: 24 hours past 6 months, on-going for next 3 years


Emergency medicine training curriculum, whether GME or UGME, does not specifically include tactical care.  While military medicine has an obvious need for such training, the majority of physician and physician-candidates may not receive any exposure to this sub-specialty.  Efforts to provide such exposure occurs though several options.

The St. Luke’s Health University Health Network Emergency Medicine Residency, Bethlehem, PA, has hosted several “Tactical Day” trainings as part of the educational component of residency.  Members of the Region 2 TEMS Team, including Rebecca Pequeno, MD, chairman of SLUHN Emergency Service and co-medical of R2TEMS, provide didactic, skills stations, and practical evolutions for EM residents. Donning ballistic vests and helmets, residents crawl to access victims and provide care under austere conditions.

ACOEP’s RSO and other programs have also taken on this educational need. The University of New England College of Osteopathic Medicine’s Emergency Medicine Club, Biddeford, ME, brought the topic of Tactical Medicine to its members.  Members of the Region 2 TEMS presented the program to UNECOM EM club.  After a didactic presentation, the club members rotated through skill stations to practice tourniquet application, wound packing, chest decompression, digital intubation and surgical airway techniques.  Energy, enthusiasm, and smiles emanated from helmets, body armor, and gas masks as future physicians took turns treating mannequin casualties and cutting pig tracheas.

Target Audience: Emergency medicine residents, Osteopathic medical students

Change: Provide exposure to tactical medicine

Funding: None found yet, pig tracheas with lungs – $10 each, offset by lobster chowder $12 a cup

Time: 36 hours

ACOEP CME – Spring Seminar, Scientific Assembly

The CME committee of the ACOEP organize the Spring Seminar and Scientific Assembly.  The programs provide excellent CME through a variety of venues, including lecture topics of casualty care, MCI event reviews, and hands-on practicals.  Presentations by providers involved in MCI events have been well attended and attendees receive information and opinions germane to EM practitioners rather than news reports.

The ACOEP EMS Committee, working with the CME Committee, has provided break-out session tracks covering the topic of Tactical Medicine and Tactical Medical Command.  An increasingly popular addition to the conferences has been the Active Shooter Training.   SWAT Physician John Dery, DO and Fire Chief Michael Roman spoke to a packed room of ACOEP course participants in San Francisco, CA, prior to skills session and scenario evolution where a hotel conference room was turned into a mock ED with multiple shooting victims.  Members of the Resident Student Organization [RSO] provided moulage victims for the single coverage EM physician, Kevin Loeb, DO, to treat in his department.  Other course attendees fulfilled roles in the ED as nurses, ward clerks, and techs.

In Bonita Springs, FL an EMS track with sessions covering the Pulse nightclub MCI, skills session at the conference hotel and, after a short bus ride, training at the county’s fire training grounds was well attended and provided life-saving information.  Working with members of fire, EMS and law enforcement, program attendees practiced as members of the RTF to attend to victims and move with the law enforcement escort.  Skills stations practice next to fire and EMS professionals filled the time between practice evolutions in the buildings with victims for the RTF maneuvers.  Riding the bus back to the hotel, sweaty, dirty, tired, and a bit sore, course participants had seen the aspects of training expected of first responders to prepare for an MCI.

This fall at the Scientific Assembly, attendees will have a chance to register for an MCI Simulation on an unprecedented conference scale. An MCI event, field hospital, surge patients, transportation issues, treatment strategy and much more. See the article for a full description.

Target Audience: ACOEP Conference attendees

Change: Provide experience in large-scale MCI drill

Funding: CME budget

Time: Worth every minute spent

Prepare to Prepare Barriers

MCIs will occur.  Low-frequency, high-risk events have no predictability.  While there has been a trend away from the denial attitude, proactive training still can meet with resistance.  Some barriers to education may be encountered.

Political correctness tends to be a line some instructors will not cross, while others trip over this line regularly.  The latest TECC course included an explanation from an instructor that phrases like “neutralize the threat” have been felt to be too graphic a description of the law enforcement activities to locate, contain, or kill the threat from a homicidal perpetrator and have upset some people in other classes.  Although the instructor’s term modification to “bunny hugs and candy kisses” can be used as code words, the magnitude in presentations of sensitive material must sometimes include a warning to the audience.

Pre-lecture instructions are given to be non-judgmental if another participant leaves the program during the presentation.  Preemptive apologies for language, germane to the topic but upsetting to some, does not decrease post-lecture complaints, but is included.  Descriptive terms of perpetrator or culprit or offender lightly gauze the true identifier not used in presentation.

Tailoring a presentation to specific audiences can be an artform.  While program core content remains unchanged, variations in presentation can be adapted to each audience.  Many CPR instructors supply students with helpful metronomes to maintain 100 BPM. Their utilization of songs for this task truly is audience dependent:  The Bee Gees or Queen.

Start Preparing to Prepare

Preparation for MCIs involves many aspects.  Educational programs which focus on improved survivability for victims exist for first responders and the public.  Available programs have content ranging from self-preservation in a workplace to military tactic recommendations. Some programs target the MCI timeline from the onset of the event until arrival of first responders.  Other programs are designed for the specific provider and their roles and actions.  Some programs are scalable to the different disciplines of first responders; law enforcement, fire, or EMS. Which program is the best in your locale?

MCI victims will arrive in an ED, during and after an event. Improving the training of the “other team” to care for victims of MCIs is an important aspect in preparation. Empowering bystanders and improving first response can save lives.

The need to prepare for MCIs is obvious.  Organizing training is difficult.  However, opportunities exist, and while no one may feel they have the time or resources to invest in such trainings, this qualifies now as a priority.

Visit www.acoep.org/news for links to these and other valuable resources.


“Run, Hide, Fight”, U.S. Department of Homeland Security, Washington, D.C. https://www.dhs.gov/active-shooter-emergency-action-plan-video

“Dealing with Workplace Violence: A Guide for Agency Planners”,  U.S. Office of Personnel Management,      Washington D.C.  www.opm.gov/Employment_and_Benefits/Worklife/OfficialDocuments/HandbooksGuides/

“Stop the Bleed”,  U.S. Department of Homeland Security,  Washington, D.C. https://www.dhs.gov/stopthebleed, October 2015

“Active Shooter: How to Respond”,  U.S. Department of Homeland Security, Washington, D.C.       http://www.dhs.gov,  October 2008

“Active Shooter: What You Can Do”,   U.S. Department of Homeland Security,  Washington D.C.      http://training.fema.gov/EMIWeb/IS/IS907.asp,  October 2008.

Tactical Emergency Casualty Care, National Association of Emergency Medical Technicians, Clinton, MS, naemt.org