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Responding to IED attacks: Improving EMS for violent mass casualty incidents

This post is co-authored by Scott Somers and Raphael M. Barishansky.

Since 9/11, firearms have accounted for 95 percent of all deaths from domestic terrorism. While IEDs remain relatively rare in the U.S. when compared with armed attack, the Boston Marathon bombing (2013) and the recent explosions in Manhattan and New Jersey (2016) warn of a growing domestic threat. Both tactics produce mass trauma casualties.

Advances in battlefield trauma care and medical technology during the wars in Iraq and Afghanistan resulted in a sharp reduction in preventable deaths in those conflicts. First-responder combat medics and corpsmen are better trained and equipped to address bullet and shrapnel wounds.

Law enforcement agencies have also adapted their tactics for violent mass casualty incidents. After the Columbine High School Shooting, police departments adopted a more aggressive response in which officers immediately pursue and neutralize an aggressor rather than waiting for a SWAT team. This change was supported by significant enhancements in officer training and equipment.

By comparison, the emergency medical services (EMS) response to violent mass casualty incidents has been slower to adapt. EMS curricula, standards and policies still largely dictate that field EMS providers wait until police mitigate the threat before entering to treat victims. While EMS responders wait for a secure scene, the injured are not receiving care resulting in potentially preventable trauma-related disability and death. Critics point to the Aurora theater shooting to suggest that some lives might have been saved had a more proactive emergency medical response procedure been in place.

To be fair, the need for better field EMS response has not gone unaddressed. Guidelines from the DHS Office of Health Affairs, US Fire Administration, and Interagency Board are just a few examples of resources developed for medical first responders. And law enforcement has begun training officers in Tactical Combat Casualty Care. But greater Federal leadership is needed to support training and equipping local, regional, and tribal field EMS providers for violent mass casualty response.

The White House should set an explicit goal. The National Academy of Science will soon recommend that the White House set a national aim of achieving zero preventable deaths after injury and minimizing trauma-related disability. Reducing morbidity and mortality among violent incident casualties would be a logical component of this goal. However, the current national Counter IED strategy makes no mention of either field EMS or the trauma care system.

The Federal Interagency Committee on EMS (FICEMS) should take the lead. A significant barrier to coordinating preparedness in the pre-hospital arena is that EMS sits at the crossroads of public health, health care, and public safety. There is no designated lead federal agency for EMS. As a consequence, the federal government has not set standards for EMS performance in the homeland security mission and some EMS provider types have received as little as four percent of DHS preparedness funding.

Congress mandated creation of the FICEMS to ensure interaction among Federal agencies in support of EMS and 9-1-1 systems. Its mission is to coordinate projects across the Federal government.

Improving field EMS interaction and interoperability during violent mass casualty incidents must be a high-priority initiative for FICEMS. FICEMS is also well-positioned to establish a cross-disciplinary effort to collect, analyze and validate best practices for pre-hospital and hospital-based response to violent mass casualty incidents, from bystander actions to field treatments and surgical care. FICEMS must also advocate among its members for proper funding for integration of all EMS provider types into the homeland security mission.

The FDA must be a partner in this process. Innovations from military medicine, such as redesigned tourniquets and utilization of hemostatic agents, have helped save lives. These treatments are supported by a large body of uncontrolled clinical evidence. FICEMS and the FDA should facilitate prehospital inclusion in randomized controlled trials of innovative trauma care.

Scott Somers, Ph.D., is a CCHS senior fellow with over 20 years in emergency medical services. He was formerly a member of the National EMS Advisory Council.

Raphael M. Barishansky, MPH, MS, CPM, is a CCHS senior fellow with over 20 years of experience in emergency medical services and public health preparedness.