EMS

Cooling Down the Warm Zone: Rescue Task Force

The Rescue Task Force model of care represents an emerging standard of operations in response to high-threat mass casualty incidents. Distinct from the TEMS model, RTF care incorporates "street-level" EMS and law enforcement personnel on-scene at the beginning of an incident.

In recent years, America has experienced an alarming increase in the frequency of mass shooting incidents. The country’s deadliest mass shooting to date took place in Las Vegas in October 2017, when Stephen Paddock fired more than 1,100 rounds into a crowd of 22,000, killing 58 people and injuring 851. These figures could have been even more tragic if it were not for the deployment of 16 rescue task forces (RTF).

An RTF includes EMS providers and law enforcement officers who work as a team to provide rapid treatment and extrication of victims while Special Weapons and Tactics (SWAT) teams work to locate and neutralize threats. This interprofessional dynamic represents a new standard of operations in response to high threat mass casualty incidents.

Background
The 1999 mass shooting at Columbine High School brought attention to the threat of domestic terrorism. In the wake of the shooting it became clear that the traditional emergency response philosophy of “contain and wait” was not effective, delaying both law enforcement and EMS entry into the building and resulting in an unnecessary loss of life.

Previously, officers would form a perimeter and await the arrival of specially trained tactical teams. During this time, EMS responders staged at a safe distance, designated as a safe zone, preventing them from becoming casualties. However, this hindered access to life-saving care.

An aggressive response is now the standard, and police will seek out and attempt to neutralize the shooter — which often renders a portion of the scene relatively safe, or a warm zone. It is here that the RTF can be employed to treat and evacuate victims.

Rescue Task Force Model
In 2009, the RTF model was pioneered by the Arlington County Fire Department in Virginia. RTF takes the evidenced-based principles of Tactical Combat Casualty Care (TCCC) that were developed by the military for field combat and adapts them to civilian populations under the framework of Tactical Emergency Casualty Care (TECC).

The RTF approach dictates that the initial law enforcement response is to enter the building and quickly engage the shooter while identifying threats and clearing a “warm zone.” The RTF is then formed by first-arriving EMS providers and law enforcement officers to move quickly into the warm zone and initiate treatment and evacuation of victims. The traditional RTF team includes 2-4 law enforcement officers and 2 EMS providers who typically wear ballistic gear and carry supplies to treat up to 14 patients.

In contrast to the “contain and wait” model, the RTF team is composed of ordinary “street” law enforcement and EMS, not SWAT team members and tactical medics. Each member of the team has a defined role. Law enforcement officers provide front and rear security and are responsible for coordinating movement, but do not provide or assist with any medical care. EMS providers in the warm zone treat only immediately life-threatening injuries such as major bleeding or airway compromise, focusing on evacuating the patient to the cold zone for further evaluation and care.

Different systems may choose to employ basic life support (BLS) or advanced life support (ALS) EMS personnel or utilize fire department first responders while reserving EMTs and Paramedics to provide higher-level care in the cold zone.

Additional models of RTF allow for a protected corridor approach where unescorted EMS providers move freely in an area with fixed law enforcement guards. Alternatively, a “protected island” casualty collection point (CCP) can be established and hardened within the hot zone with law enforcement transporting victims to the CCP for stabilization.

In systems with significant law enforcement resources but a lack of EMS providers, police rescue teams can be utilized to evacuate patients to the cold zone. RTF allows for continual pursuit of the suspect while simultaneously decreasing the length of time needed for injured victims to receive medical care.

While the RTF model involves EMS providers working in close proximity to an area of hostility, this system should not be confused with Tactical Emergency Medicine Services/Support (TEMS), detailed in previous EM Resident articles. TEMS providers receive extensive tactical training and are embedded within SWAT teams with the primary mission of providing preventative and emergency medical care to team members. TEMS providers may be armed and accompany the team on all routine and emergency call-outs.

In contrast, RTF pairs “street-level” EMS and law enforcement to rapidly access, treat, and extricate victims from an active threat event.

Moving Forward
As the RTF model continues to gain support, emergency physicians can provide valuable medical oversight and training to help EMS and law enforcement work together efficiently. This should be practiced long before an actual event takes place.

An example of this was done by the New York State Division of Homeland Security and Emergency Services. Over a 2-day course, responders practiced RTF movement, hemorrhage control, and triage. They also applied concepts such as decision-making and peer leadership to culminate in a scenario-based simulation. This is the type of cooperation and effort it will take for RTF to reach its full potential and save lives in the future.


References
1. Criss D. The Las Vegas attack is the deadliest mass shooting in modern US history. CNN. Updated October 2, 2017. Accessed January 31, 2018.
2. Bui L. Armed with a new approach, police and medics stormed through the Las Vegas gunfire, saving lives. The Washington Post.. Accessed January 31, 2018.
3. Smith ER, Iselin B, McKay WS. Toward the sound of shooting: Arlington County, Va., rescue task force represents a new medical response model to active shooter incidents. JEMS. 2009;34(12):48-55.
4. Kue R, Kearney B. Transitioning to warm zone operations. JEMS. October 2014; Suppl:22-6.
5. Meoli M, Rathbun D. Being ready to deploy: Interoperable core skills for training to respond to violent incidents. JEMS. October 2014; Suppl:34-40.
6. Hardy J, Mehkri F. Protecting the protectors: Physician roles in tactical emergency medicine Support. EM Resident. 2017;44(3)28-29.
7. New York State Division of Homeland Security and Emergency Services. 18 EMS responders complete new ‘Rescue Task Force for EMS’ course at state preparedness training center. JEMS. June 2017.

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