Official journal of the Australian Tactical Medical Association

Mass casualty incidents and tactical medical capabilities amongst first responders:

2018 IPSA Study grant report

Jason Hartley1

1 Detective Senior Constable; Western Police Force, , Australia

Introduction

In August 2018, I was awarded the first responders, such as Law Enforcement inaugural Australian Tactical Medical Officers (LEOs), Paramedics/Emergency Association (ATMA) study grant to attend Medical Services (EMS), Firefighters and the International Public Safety Association other emergency personnel. (IPSA) Fall 2018 Symposium in Virginia, United States of America (USA) and Due to operational sensitivities, some conduct research in tactical medical information or conversations from methodologies utilised by first responders. engagements is redacted. This, however, has not affected the substance of this This report outlines the outcomes of my report nor its recommendations. objectives for the study grant: 1) Record the content and lessons My goal for this study grant is to promote learnt by attendance at the awareness and education to groups or International Public Safety organisations which have had limited Association (IPSA) 2018 Fall exposure to tactical medical methodologies Symposium; and or MCIs. Through simple knowledge and 2) Explore tactical medical equipment, survivability amongst victims methodologies, particularly within and first responders can be significantly law enforcement and its application improved. to Mass Casualty Incident (MCI) response. This report is created for the Australian Tactical Medical Association and outlines attendance at the International Public Safety Association The IPSA Fall 2018 Symposium primarily 2018 Fall Symposium and the content of focused on MCIs and the planning, engagements with the United States of America response and recovery to such incidents by first-responder agencies.

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Table of Contents

Introduction ...... 1 Arlington County (Police and Fire/EMS) ...... 3 Metropolitan Police Department of the District of Columbia ...... 4

International Public Safety Association 2018 Fall Symposium ...... 5 Keynote Speaker - Lieutenant and Chief Medical Officer Alexander Eastman, Dallas Police Department...... 5 Dr Kari F Jerge MD FACS, Kansas University ...... 6 Intensive Care Paramedic Oliver Ellis, Australian Tactical Medical Association ...... 7 Paramedic Supervisor John Reed, Danbury Hospital EMS ...... 9

Federal Bureau of investigation (Critical Incident Response Group) ...... 10

Recommendations ...... 11 Recommendation 1: Australian first response agencies adopt Tactical Emergency Combat Care (TECC) guidelines...... 11 Recommendation 2: Australian first-responders and emergency departments increase interoperability between agencies...... 11 Recommendation 3: Australian law enforcement and related agencies employ Medical Officers to oversee medical capabilities...... 11 Recommendation 5: commission a committee to assess and enhance first responder medical capability at MCIs...... 12 Recommendation 6: Australian agencies commission timely after-action assessments for MCIs, to ensure that lessons learnt are available with minimal delay...... 12

The statements and opinions expressed in this report are those of the author and do not necessarily represent the position, views or policy of any agency, organisation, employer or company. Although the author and Australian Tactical Medical Association (ATMA) have made every effort to ensure that the information in this report is correct, the author nor ATMA take any responsibility for the accuracy of the information contained in this report

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Arlington County (Police and training or medical equipment to deal with Fire/EMS) the incident and are reliant on first responders to preserve life and prevent Having developed the Rescue Task Force further injury. (RTF) model, Arlington County Fire Department (ACFD) is at the forefront of A key note is that this is counter to current Tactical Emergency Casualty Care (TECC) Australian civilian first aid methodology and Warm Zone care. ACFD has a where first responders are taught to not put dedicated High Threat Response Program themselves in harm’s way (D for Danger (HTRP) who develop, train and integrate within the DRSABCD paradigm). members of their FD and Arlington County (Australian Resuscitation Council, 2016) Police Department (ACPD) to improve response capability at MCIs. The second fundamental is the driving force of the current mission, which is Annual training provided to ACFD and defined as either Tactical or Medical: ACPD includes refreshers for TECC  If tactical, neutralisation or principles and related equipment (such as containment of the threat is the priority tourniquets and chest seals). Scenario- and law enforcement officers (LEO) based training is provided to ACFD & must move past casualties to deal with ACPD by utilising ‘dispatch’ to send the threat. available units to an approximately one-  If medical, the threat has been hour event before returning to regular neutralised, contained or is absent and duties. the priority is placed on treating victims and innocent parties. Evident was inter-operability and effective working relationships between agencies, I also noted the following key points in with training being conducted at the same relation to ACPD: location and regularly involving both  Tourniquet carriage is mandatory (held agencies. Coupled with this inter- on the tactical vest or support pants- operability training, is the reinforcement by pocket). trainers of ‘Unified Command’.  Individual first aid kits (IFAKs) are issued to LEOs, which are normally The training delivery focuses on TECC stored over the passenger’s headrest guidelines, however, I identified two as a ‘go’ bag (immediately accessible). fundamental principles. The first is the  Regular active shooter/ Active Armed priorities of life (in descending order): Offender (AAO) training is conducted 1. Victims and Innocent Parties as a one and two-officer response. 2. Public Safety (Police Officers, First

Responders etc.) ACFD carry all necessary equipment for 3. Perpetrator/s. warm zone care, including ballistic PPE,

specialist medical equipment and triage This fundamental is reinforced to ensure tags. Arlington County demonstrated a first responders understand that the victims well-drilled and developed tactical medical and innocent parties are the first priority. program for Police and Fire/EMS, built on Victims or innocent parties generally have TECC guidelines. This observation is no personal protective equipment (PPE), supported through ACFD delivering TECC

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& RTF training to other USA jurisdictions and plain-clothes officers arrived and its reference in TECC/Tactical Medical carrying rifles without being easily publications. identifiable as LEOs.  MPDC LEOs had limited appreciation Metropolitan Police Department of of the Navy Yard site and were unable the District of Columbia to locate the scene as it was described as ‘Building 197’ (not cross streets as The Metropolitan Police Department of the LEOs normally use). District of Columbia (MPDC) is the primary  LEOs were initially refused entry onto law enforcement agency for D.C. and one the base as it had gone into lock-down. of the 10 largest local police agencies in the  Attending LEOs all entered the Hot USA. Zone, including the supervisor who

may have been better served by On 16 September 2013, an offender1 creating a command post. entered the Washington Navy Yard, gaining access through his role as a current  Information received was inaccurate at contractor. Over the next 69 minutes, he best, attending LEOs did not know how killed 12 people and injured several more many shooters were involved, their (Metropolitan Police Department, 2014). location or their movements.  911 was overwhelmed with calls During this active shooter MCI, the offender resulting in information over-flow to armed himself with a shotgun he legally attending LEOs. owned and a handgun he took after killing  Human nature is a “funny thing” and a security guard. Entering Building 197, he you shouldn’t expect people to do what fired indiscriminately and engaged in is best for them. Some victims did not multiple shoot-outs with responding law run or hide, they simply froze when enforcement (Metropolitan Police they were confronted by the shooter. Department, 2014).  Emergency response vehicles obstructed the roadways in and out of This devastating MCI ended when the the incident. offender jumped out from behind a cubicle  As it occurred on a US Navy base, and engaged an MPDC Special Operations jurisdictional issues resulted in a Team tactical operator. During this final significant delay for the scene to be confrontation, the engaging MPDC officer processed (deceased victims were left was shot by the offender with his ballistic at the scene longer than was vest collecting the round. He was able to necessary). return fire, killing the offender instantly  ‘Unified Command’ is not simply (Metropolitan Police Department, 2014). having the highest ranked person in Lieutenant C. and Captain M. had first- charge but the person with a hand involvement with the Navy Yard MCI combination of experience, leadership and described it as follows: and knowledge.  The attendance at the scene was  Without significant training, it is difficult chaotic. Some unit’s self-dispatched for LEOs to enter a hot zone where

1 The name of the offenders (perpetrators) through this report have been withheld out of respect for the victims.

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their life is in direct threat. Some ‘blue on blue’ incidents (due to the officers (despite training to engage difficulty in identifying plain-clothes with active shooter/active armed officers). offender) held positions awaiting  To further survivability in MCIs, MPDC MPDC Emergency Response Team. engages with the community and business owners to promote public Lieutenant C. and Captain M. stated the education programs relating to MCIs, Navy Yard Shooting was a catalyst for such as the Department of Homeland widespread change and spoke about Security’s ‘Stop the Bleed’ program. changes within the MPDC, post the Navy Yard MCI: Like Arlington County, MPDC has adopted  ‘Unified Command’ is now a major the TECC guidelines and makes its emphasis of command training in the principles fundamental to its AAO/MCI MPDC. response. Tragically, MPDC and DC’s  Correct physical location selection for other first-responders have experienced an a command post is paramount to MCI, of which they significantly progressed ensure it maintains an ability to their capability and response post-incident. command and is not ‘caught up’ in the incident itself. International Public Safety  Memorandums of understanding Association 2018 Fall Symposium (MOU) are now in place with all major Keynote Speaker - Lieutenant stakeholders relating to MCIs, outlining and Chief Medical Officer subjects such as response and Alexander Eastman, Dallas ownership of particular responsibilities Police Department. pre, during and post MCI.

 For critical or key infrastructure, first responders consider pre-defined A Personal Story from the Dallas Police Casualty Collection Points. Ambush Attack: Improving Survival from  Family reunion points are established Active Shooter Events otherwise members of the public will try and enter the scene. On 7 July 2016, 800 people gathered near El Centro College, Dallas, Texas for a  A recognition that interagency training Black Lives Matter protest. 100 Police between first responders is paramount provided crowd control for what was at that to an effective response. moment, a peaceful protest. At the same  Initial and yearly refreshers of TECC time, an offender armed himself and and ‘Active Violence’ (Active entered the Dallas downtown area. Shooter/AAO) training is conducted

amongst LEOs. After four hours, the incident ended with  Carriage of tourniquets is now Dallas PD deploying a robot rigged with C4 mandatory by LEOs (IFAKs are into a toilet where the offender had optional but encouraged). retreated. It was detonated, killing the  The District of Columbia Fire and offender and making history as the first Emergency Medical Services provide time American Law Enforcement had used warm zone care through an RTF. explosives as a use of force. 12 Police  Plain-clothes officers no longer Officers had been shot, five of which killed, respond to MCIs, primarily to prevent

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two civilians wounded and 300 casualties  Dallas PD now trains to move their would soon present themselves to nearby own casualties and do not wait for an hospitals. ambulance.  During this MCI, Dallas PD had no Dr Eastman provided a first-hand account communications to the hospital. of the incident as a member of the Dallas  Dallas PD and other Police can now PD Special Weapons and Tactics (SWAT) talk to the trauma centre directly, Team; Medical Director for the Dallas PD which is critical when transporting and as medical director for The Rees- patients. Jones trauma center at the nearby  Police departments should build Parkland hospital. Providing immediate relationships with your hospitals and response to the incident from four blocks trauma centres. away, Dr Eastman describes the chaos as  When an officer requires urgent he approached the scene, with vehicles backup, Dallas PD now initially self- abandoned and members of the public dispatch at the highest priority. This screaming, running and filming the prevents communications from being incident. The sound of gunfire from the overwhelmed and allows offender’s weapon ricocheted through the communications to stay open to relay CBD area and Police were unsure of how critical information. many offenders were involved. ‘Stop the Bleed’, a program initiated to Situational awareness is key, as Dr empower members of the public to engage Eastman broke it down to the following key in life saving haemorrhage control saves points: lives and is a program that should continue  Radio communications during the to be implemented to the community. incident were calm for the most part.  Police officers provided TECC to Dr Eastman draws attention to the fact that injured officers, which saved their in any disaster, the long term psychological lives. impact is far greater than the initial impact  The fog of war is real, Police had no and we need to care for ourselves and idea what was going on. each other.  The hot/warm/cold zone could not be defined (the offender was moving and ‘Psychological first aid’ is a new program these zones were constantly that Dr Eastman is actively promoting. changing). Sadly, there are Dallas LEO’s who no  The first 6 to 10 minutes is crucial, longer protect the community and the on- particularly in the provision of medical call surgeon for this MCI is no longer care. practicing.  The non-traditional (medical)  providers made the difference Dr Kari F Jerge MD FACS, (civilians and Police). Kansas University

In relation to communications, Dr Eastman Medical Response to a Man-Made Mass makes the following points: Casualty Incident

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The USA is experiencing an increase in the Dr Jerge stressed the importance of EMS frequency, severity and visibility of MCI. being able to enter the warm zone for Offenders are modifying tactics to increase evacuation and initial treatment, effectiveness, such as adopting positions highlighting Arlington County has one of of elevation and using objects such as the most evolved RTF models. vehicles as weapons. The resulting wound profiling is not often seen by Emergency The local trauma centre has implemented Medical Services (EMS) or medical a surge capacity with corresponding plans professionals. The majority of these attacks and training to ensure staff are aware of create complex injury patterns, such as one what to do in their response to an MCI. This or more penetrating trauma injuries, blunt exists through building a public-private trauma and burns. These injury patterns relationship and examples of these plans mirror military wounding profiles and include the University of Kansas Medical present a challenge for civilian first Centre credentialing other medical staff so responders. Dr Jerge describes this setting they can come in as support for an MCI. Dr as a ‘civilian combat zone’. Jerge provides an example of the demand levels during an MCI, highlighting the 1,502 An MCI or active threat scenario requires a related ‘911’ calls the Las Vegas different medical response with Dr Jerge Metropolitan Police Department answered stressing the need to incorporate combat in the first two hours of the Las Vegas medical principles into the civilian arena. Shooting (Clark County Fire Department, She questioned why the current treatment Las Vegas Metropolitan Police paradigm is ABCDE, noting the low Department, Federal Emergency preponderance of death from airway Management Agency, 2018). obstruction in these circumstances. Recent examples include the Pulse nightclub In closing, Dr Jerge highlighted the shooting. importance of the ‘Stop the Bleed’ program for civilians explaining that they are the first In man-made MCI, the triage of patients is to provide medical care during and after an much more difficult. There is normally an MCI. Bleeding control kits should be active, on-going threat with complex located next to Automatic External mechanisms of injury. In the Virginia tech Defibrillators (AEDs) and Tactical Combat shooting, the over-triage rate was 69% Casualty Care (TCCC) or TECC is (Turner, Lockey, & Rehn, 2016). Dr Jerge important in MCI response and needs suggests that whatever model of triage widespread implementation. agencies use, they should keep it simple. Intensive Care Paramedic Oliver In MCI, civilian bystanders will get involved, Ellis, Australian Tactical Medical I note this point as particularly evident in Association Australia, with footage from hostile vehicle attacks in Melbourne in 2017 and 2018 Baptism by Fire: The Martin Place Siege showing initial medical aid being provided and the Birth of the Current Australian by civilians and police, not EMS (Nine Medical Response to Terrorism Digital pty Ltd, 2019). On 15 December 2015, an offender entered the Lindt Café in Martin Place,

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Sydney, (NSW),  NSWAS had no direct communication Australia. The offender took eight staff with Police (e.g. no shared radio members and 10 customers hostage in the channel). name of Islamic State (Coroners Court of  NSWAS members staged to respond New South Wales, 2017). Over the next 16 to the incident were not aware that an plus hours, in four separate events, twelve ‘Emergency Action’ was occurring of the 18 hostages escaped. The following (2.13am). day, at about 2.13am, the offender  There was triage confusion when executed the store manager Tori Johnson. assessing causalities. Police Tactical Operators subsequently stormed the café and engaged the Equipment: offender, who was killed, along with  NSWAS had no specific medical hostage Katrina Dawson, who was struck equipment for MCIs. by a fragment or fragments of a deflected  NSWAS had no tactical extraction police bullet or bullets (Coroners Court of equipment, only conventional New South Wales, 2017). stretchers.  Some NSWAS members staged near Prior to the events at Lindt Café, the New the scene were without adequate South Wales Ambulance Service ballistic PPE resulting in Police (NSWAS) primarily associated MCI with needing to provide them with ballistic naturally occurring events (not man-made). PPE. Whilst the 1996 Port Arthur MCI, in which  Equipment possessed by NSWAS 35 people were killed by a single offender Special Operations members was in (R v. Martin Bryant, 1996) outdated and not suitable for warm brought the scope of man-made incidents zone operations, examples included to the forefront, it had been almost 20 years the high-visibility reflective striping on since a mass shooting in Australia. their uniform and medical packs.

As events at Lindt Café unfolded, the initial Lessons learnt: EMS/paramedic response was coded as  A formal debrief is required for mental an ‘R8 special event’ to assist the NSW health and to identify issues. Police Force, Tactical Operations Unit  Holistic training is required between (Police Tactical Group). There was no ‘000’ agencies. (emergency call) to NSWAS nor any  Equipment was not suitable for the understanding of what the initial operational environment. responding members were attending. Mr

Ellis outlines the following issues and Whilst the majority of presenters at the lessons. IPSA 2018 Fall Symposium were from the

USA first-responder community, Mr Ellis Attendance: outlined valuable lessons and  NSWAS was initially staged in a hot considerations for planning, preparing and zone with a line of sight to the Lindt responding to MCIs: Australian first Café. responders need to plan and prepare for  Command Posts were geographical similar events. difficult to access and scattered, with

no true Unified Command.

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Paramedic Supervisor John two paediatric patients, leaving Mr Reed as Reed, Danbury Hospital EMS the only EMS at the scene. He was never told it was an active shooter incident, nor Community Resilience: Applying Lesson did he have any idea about the traumatic Learned from the Sandy Hook Shooting event that he was going into.

On 14 December 2012, a 20-year-old Upon entering the school, Mr Reed offender entered Sandy Hook Elementary distinctly recalled the haze of gunpowder School (SHES) in Newtown, Connecticut, and sensory overload. As he turned left and USA where he shot his way into the approached the first classroom, a Police building and killed twenty children and six Officer maintained the entryway to the adults (Stephen J. Sedensky III, State's classroom. Upon moving into the room, Mr Attorney (Connecticut), 2013). Reed observed 17 casualties, all with catastrophic injuries (not compatible with Newtown, Connecticut is a community of life). Mr Reed moved to the second 28,000 people, with 46 members of the classroom to see further victims, again all Police, volunteer EMS staff and five with catastrophic injuries and the shooter volunteer firefighters. It is a small, affluent with a self-inflicted gunshot wound to the community where a layman would never head. expect an MCI like this to occur. Despite no victim being viable, Mr Reed John Reed provided a personal and quickly formulated a plan of action genuine presentation on an event which understanding the scrutiny that the first few first responders have experienced, and responders would soon face. Without any one even fewer are able to talk so openly additional EMS or Fire support, Mr Reed and publicly about. A TCCC instructor, T- conducted a full assessment of each victim EMS element leader and 30-year EMS and ensued triage was complete (with all veteran, Mr Reed provides a qualified casualties assessed as deceased). presentation focusing on preparedness and effects on the community as a result of In his admirable account, Mr Reed focuses an event like this. on the post-incident effects to the first responders and the community as a whole. On 14 December, John Reed was on-duty The coming days were a total blur for Mr in a neighbouring area outside Newtown, Reed however he returned back to work providing ambulance services. When first shortly after the incident. Rumours hearing of the incident at SHES, Mr Reed circulated that Mr Reed and others had knew it was in neighbouring Newtown and self-dispatched, even though this wasn’t initially thought it wouldn’t be his problem. the case. Not long after, he was dispatched to the incident, swapping out his ambulance for a 4 days post the incident, an FBI ‘fly-car’ (non-transporting EMS vehicle) to psychologist conducted a debriefing with provide a rapid and tactical medical (T- Mr Reed, informing him he had PTSD and EMS) response. was ‘broken’ from the incident, making him feel worse and further deteriorating his As Mr Reed arrived at the scene, condition. Mr Reed described this debrief neighbouring Newtown EMS departed with as a complete waste of time that did not

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help at all. Instead, Mr Reed promoted 2) Post-incident management of first talking to the other first responders responders is vital. These events involved in the incident as the best support. ruin careers, with some responding Police and EMS to Sandy Hook Mr Reed makes the following key points never returning to operational duty. relating to MCIs. “You have to develop a mindset that this Planning: will happen to you”  Understand and develop a mindset – Paramedic Supervisor John Reed that this can happen to you and your family. Federal Bureau of investigation  Develop Standard Operating (Critical Incident Response Procedures (SOPs) for MCIs. Group)  Get EMS involved in planning and Within the FBI is the School of Operational training. Medicine (SOM), responsible for FBI  TECC training is essential for first agency-wide training and development of responders. medical capabilities which have been  All agencies need to train in TECC incorporated by all field-agents of the FBI, together. irrespective of role or location.

Response and Recovery: The Law Enforcement Field Agent (LEFA)  A response to these incidents must be program is a one-day (9 hour) package a team approach by all agencies. covering the following medical related  Keep additional first responders away skillsets: from the aftermath, they don’t need to  Underpinning knowledge/principles of see it. operational medicine and TECC.  Keep first responders away from the  CPR and AED skills. media.  Haemorrhage Control.  The town was overwhelmed,  Basic Assessment. especially when additional resources  FX (Fracture) Management. were required to deal with the  Narcan (Naloxone) Administration. subsequent presidential and other VIP  Calling 911 and Patient Movement. visits.  There must be an after-action The FBI LEFA training is in-line with debriefing. TECC/TCCC guidelines, allowing for an  Questions need to be asked, are these inter-agency application. In discussing the people ready to go back to work? What progression and development of tactical process is in place to support them? medical capabilities in Australia, the SOM spoke of the importance of TECC Whilst all these points have merit, the two principles, including identifying your driving central points from Mr Reed’s presentation force (tactical or medical) and the were: importance of every Police Officer to have 1) It will happen to you, so prepare for this know ledge and skillset an incident like this (Newtown was a small town in an affluent area of Connecticut).

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Recommendations Hand-in-hand with this recommendation is the clear requirement for every operational A key purpose of this report is to provide a member of first-response agencies to proxy relaying the lessons learnt in the receive adequate TECC training. USA so that Australia does not have to re- learn lessons from inadequate responses Recommendation 2: Australian and the loss of life associated with MCIs. first-responders and emergency The following recommendations are from departments increase the results of my study grant and my interoperability between experience of being a Police Officer for the agencies. past ten years.

Recommendation 1: Australian The prevailing discussion point through this first response agencies adopt study grant was the requirement for an TECC guidelines. effective interagency capability and role appreciation to ensure an adequate response to MCIs. The adoption of TECC guidelines provides first responders with identified best- A once-a-year ‘sugar hit’ of interagency practice capabilities in initial medical care, training is insufficient to meet inter-agency particularly in the case of MCIs. Whilst operational effectiveness. Integrated some USA agencies operate with slight TECC training, as well as an on-going and variations to the guidelines, they are similar diverse array of activities (e.g. training, enough to ensure first responders all tours and exercises) between each operate under TECC. echelon of agencies, is required to truly achieve this recommendation. Interlinked with this recommendation is the need for Firefighters and Paramedics Recommendation 3: Australian (EMS) to provide medical support within a law enforcement and related warm zone of an MCI or similar incident, agencies employ Medical such as those evident from USA RTF Officers to oversee medical programs. Firefighters and Paramedics capabilities. already conduct at-risk duties, such as emergency driving (lights and sirens) or entering hazardous/burning buildings but Responsibility for the medical direction, there appears to be limited appetite in capability and training of larger USA law some services for their members to provide enforcement agencies is through the warm zone care. To support appointment of a medical officer. Given the implementation and mitigate risk within a larger size of law enforcement agencies in warm zone, there is a need for emergency Australia (when compared to the average services to provide members with in the USA), there is a need for the appropriate PPE, training and other appointment of suitability qualified medical protective measures. With adequate officers. These appointments would ensure controls, the risk to Firefighters and each agency is current with the needs of Paramedics would be comparable to other, the community and medical best-practice, current practices. with a by-product of mitigation to corporate risk relating to medical capabilities.

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committee or other syndicate to provide Recommendation 4: Australian direction and policy recommendation to law enforcement and related state and federal government agencies and officers to receive appropriate the private sector. This committee should training and equipment for the be commissioned and endorsed by the delivery of initial medical care. Australian Government for legitimacy and strategic emphasis. This committee should Australian law enforcement officers should be made up of agency medical officers (as be equipped to provide medical aid for described in Recommendation 3) and an injuries they most frequently observe: array of representatives to ensure Trauma. Core skills such as CPR are adequate and best-practice medical critical however, Police officers are more capabilities exist for MCIs. likely to come across trauma-related injuries through their daily duties. Recommendation 6: Australian agencies commission timely A law enforcement officer’s capabilities after-action assessments for should include live-saving interventions MCIs, to ensure that lessons commonly required in the treatment of learnt are available with minimal trauma injuries. These treatments should delay. include but not be limited to massive haemorrhage, tension pneumothorax, The USA has identified a need for airway obstructions and hypothermia. information and lessons learnt from an MCI Implementation of this recommendation to be disseminated as soon as practicable would positively influence survivability for after the incident. Whilst 44 casualties of trauma. recommendations were made during the

inquiry into the Lindt Café siege, these Recommendation 5: Australian recommendations took 890 days to be Government commission a presented from the time of the incident. committee to assess and (Coroners Court of New South Wales, enhance first responder medical 2017) Comparatively, the Las Vegas capability at MCIs. Shooting After-Action Report was completed 327 days after the incident. USA agencies have identified the need for a collaborative approach across agencies A major emphasis within the USA is to and jurisdictions. Whilst there is no official review and relay information from MCIs to committee within the USA Federal other first responders to assist in their Government, they have made significant preparation and response to the next headway through agencies or programs incident. This recommendation is not to such as the Committee for TECC, DHS deter, remove or change any judicial ‘Stop the Bleed’, National Fire Protection process (coronial inquiry etc.) but to Association 3000™ and IPSA. provide a mechanism for timely information to first responders and their parent In Australia, ATMA actively promotes the agencies. improvement of first responder medical capabilities however the country requires a

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References

Australian Resuscitation Council. (2016, January). Australian Resuscitation Council. Retrieved from ANZCOR Basic Life Support Flowchart: https://resus.org.au/guidelines/flowcharts-3/ Clark County Fire Department, Las Vegas Metropolitan Police Department, Federal Emergency Management Agency. (2018). 1 October After-Action Report. Committee of Tactical Emergency Casualty Care (C-TECC). (2018). Guidelines. Retrieved from http://www.c-tecc.org/guidelines Coroners Court of New South Wales. (2017, May). Inquest into the deaths arising from the Lindt Café Siege. Department of Justice (NSW). Retrieved December 2018 E Reed Smith, MD, Geoff Shapiro, EMT-P, Babak Sarani, MD. (February 2016). The profile of wounding in civilian public mass shooting fatalities. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/26958801 Jacobs LM, Eastman A, McSwain N, Butler FK, Rotondo M, Sinclair J, Wade DS, Fabbri WR. (2015). Improving Survival from Active Shooter Events: The Hartford Consensus. Retrieved from https://www.bleedingcontrol.org/about-bc/hartford- consensus Metropolitan Police Department. (2014). After Action Report of the Metropolitan Police Department Internal Review Team. Retrieved from https://mpdc.dc.gov/publication/mpd-navy-yard-after-action-report Nine Digital Pty Ltd. (2019). Bourke Street Stabbing: Bystanders rush to aid of man 'stabbed in face'. Retrieved from https://www.9news.com.au/national/2018/11/09/23/21/bourke-street-stabbing- witness-accounts R v. Martin Bryant (Supreme Court of Tasmania November 22, 1996). Stephen J. Sedensky III, State's Attorney (Connecticut). (2013, November). Report of the State’s Attorney for the Judicial District of Danbury on the Shootings at Sandy Hook Elementary School and 36 Yogananda Street, Newtown, Connecticut on December 14, 2012. Retrieved from http://www.ct.gov/csao/lib/csao/Sandy_Hook_Final_Report.pdf Turner, C. D., Lockey, D. J., & Rehn, M. (2016). Pre-hospital management of mass casualty civilian shootings: a systematic literature review. National Center for Biotechnology Information, U.S. National Library of Medicine. United States Federal Emergency Management Agency Clark County (Nev.). (2018). 1 October After-Action Report (2017 Las Vegas Shooting). Retrieved from https://www.hsdl.org/?abstract&did=814668

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