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

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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.

A difficult dichotomy for American policing

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The so-called “militarization of police” became a topic of intense political conversation after the officer-involved shooting of an unarmed 18-year-old man in Ferguson, MO in August 2014, followed by days of civil unrest. American police departments have been criticized for stockpiling military-grade weapons and gear, which are often used for routine raids, such as serving search warrants, or deployed against protestors, as was done in Ferguson. Critics question whether such equipment is needed by police.

In May, President Obama announced changes to a key federal program transferring such equipment from the Department of Defense to local police, the 1033 Program. The federal government will no longer provide certain types of “heavy military” equipment, including large caliber weapons and ammunition, and law enforcement agencies must submit to stringent federal oversight and restrictions for other equipment, such as riot gear and wheeled armor and tactical vehicles.

But the San Bernardino mass shooting, like the Paris terror attacks, has added another perspective to the debate over “militarization” and what equipment and tactics local police should have access to.

Recent attacks have demonstrated a shift in terrorist tactics where they are no longer interested in negotiating, are heavily armed, and attack ‘soft’ targets with the intent of killing as many people as possible. Speaking on Face the Nation, New York City police commissioner, William J. Bratton, called the Paris attacks a “game changer” for law enforcement. Former Chicago superintendent, Garry McCarthy, acknowledged that terrorists are changing tactics and told his officers, “We’re going to be in a combat situation if these things happen and we have to adjust our strategies in that way.”

U.S. police officials are not alone in advising more aggressive police tactics. Police officials in Europe are demanding heavier weapons and protective gear for counter-terrorism response. In Britain, Metropolitan Police assistant commissioner, Patricia Gallan, said officers are being trained to “go forward” to confront terrorists.

Indeed, law enforcement has been shifting tactics since the attacks in Mumbai, India. Ordinary patrol police are increasingly expected to confront active shooters without waiting for more heavily armed SWAT teams. Armed with little more than handguns, these officers face heightened danger as evidenced by the death of University of Colorado police officer Garrett Swasey who was killed intervening in the Planned Parenthood shooting in Colorado Springs.

Ferguson and San Bernardino present a conundrum for law enforcement. One one hand, police need military-grade equipment and new tactics to counter new terrorist tactics. San Bernardino county law enforcement has been the beneficiary of $5.8 million in 1033 Program surplus equipment since 2006; some of which was likely used in the Inland Regional Center response. Equipment acquired through the 1033 Program was on hand during the Boston Marathon bombing.

Ultimately, though, police officers must be peacekeepers, not warfighters. The greatest asset in the fight against terrorism is positive police-community relations – which requires building public trust. Now, more than ever, community policing is essential. Police must cultivate robust and ongoing relationships, especially in immigrant and Muslim communities.

Scott Somers, Ph.D. is a senior fellow at the GW Center for Cyber and Homeland Security and Professor of Emergency Management at Arizona State University.

Protecting 911 call centers from cyber threats: Federal action needed

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The growing threat of cyber attacks on 9-1-1 call centers, also known as public safety access points or PSAPs, has become a serious homeland security concern. PSAPs are the public’s vital link to life saving emergency services. As of March 2015, there are some 5,906 primary and secondary PSAPs in the United States, to which 240 million calls are made to 9-1-1 each year. The next generation of public safety communications will be even more reliant on information technology.

Existing narrowband, circuit switched 9-1-1 networks carry only voice and very limited data, so PSAPs have focused largely on preventing Telephony Denial-of-Service attacks. Advancements in Next Generation IP-based systems and emerging mobile technologies increase the threat of infiltration and exploitation of emergency communications systems. Next Generation 9-1-1 (NG911) systems will be a “network of networks” providing connectivity between PSAPs regionally and nationally. As these systems become connected to the Internet, public safety communications will be increasingly vulnerable to the same threats as other IP networks.

NG911 will allow our growingly wireless society to access 9-1-1 through texting and mobile apps, as well as send images, videos, emails, and other documents…any of which could contain embedded viruses that rapidly infect the network. First responders are also making greater use of data and cloud computing. Sensitive public safety information stored on the cloud such as emergency medical patient care reports and police body camera video could become targets for cyber hacking.

Unfortunately, information sharing across all levels of government and the private sector is lacking, often leaving local public safety blind to the latest threats to public safety cyber infrastructure. PSAPs may not be aware of steps that should be taken to mitigate emerging threats to networks.

Ultimately, the primary responsibility for protecting critical NG911 infrastructure lies with PSAP owners and operators themselves. But the federal government has a crucial facilitative role to play in public safety cyber security, which includes:

  • Protecting critical infrastructure. DHS has begun collaborating with public safety sector stakeholders to address cyber security implications of information and communications technology through the National Infrastructure Protection Plan. DHS must continually engage NG911 and Nationwide Public Safety Broadband Network officials to create sector-specific plans within the NIPP framework.
  • Providing forums where industry stakeholders can engage in risk assessment and mitigation. The federal government needs to work with public safety agencies, and engage private communications and cloud service providers, to ensure the security of critical infrastructure from cyber threats. Use of models for information sharing, such as the Multi-State Information Sharing and Analysis Center (MS-ISAC), must be encouraged.
  • Providing tools for prevention and intervention. The federal government should disseminate cyber intrusion, detection, and prevention tools to public safety partners, and be permitted, when required, to provide assistance to localities and other entities in addressing and repairing damages from a major cyber-attack and for advice on building better defenses.
  • Improving information sharing. The multiple cybersecurity information sharing bills currently being considered in the House and Senate would require federal agencies to develop and promulgate procedures to promote the timely sharing of cyber security threats to prevent or mitigate adverse effects. Congress must work to pass legislation that removes existing impediments and improves incentives for information sharing, while also safeguarding the civil liberties and privacy of citizens.

Scott Somers is a senior fellow with the GW Center for Cyber and Homeland Security and sits on the Center’s Preparedness and Infrastructure Resilience task force. He previously served on the FirstNet Public Safety Advisory Council and SAFECOM Executive Committee.