Recommendation for a National Standard for Tactical Emergency Casualty Care and Israeli Hospital Trauma Protocols for the United States

Robert L. Kierstead


pdfActive shootings and terrorist attacks have increased at an alarming rate in

recent years in the United States. According to research conducted by the Federal Bureau

of Investigation (FBI) and Texas State University, between 2000 and 2013, 486 people

were killed and another 557 were wounded in 160 separate active shooter incidents.1 Data

gathered by U.S. Department of Homeland Security’s (DHS’s) National Consortium for

the Study of Terrorism and Responses to Terrorism indicates that 208 terrorist attacks

took place in the between 2001 and 2011 in the U.S.2 Active shooter and other mass

casualty incidents require the deployment of extensive law enforcement and emergency

medical resources. While the primary police mission at these incidents is to neutralize

threats, firefighters and emergency medical services (EMS) personnel must administer

on-scene medical aid to victims. The quintessential public safety response to active

shooter events is one in which law enforcement and emergency medical responses are

integrated. However, multi-disciplinary responses to contemporary mass shootings in this

country, such as those that have taken place in Aurora, Colorado (Century Theater in

2012), Washington, D.C. (Washington Navy Yard in 2013), and the Los Angeles World

Airport (LAX in 2013), have been disjointed rather than consolidated. In fact, most

jurisdictions in the United States have insufficient resources and protocols in place to

administer emergency medical services at mass casualty incidents.

The primary purpose of this research is to demonstrate the need for public safety

jurisdictions in the U.S. to adopt dynamic tactical emergency programs to ensure the

delivery of medical services at mass casualty incidents. This is because penetrating and

blunt trauma injuries sustained by victims in active shooter and terrorist attacks, such as

gunshot and shrapnel wounds, cause massive hemorrhaging and can be fatal in minutes,

unless treated quickly. Furthermore, the administering of emergency medical services in

mass casualty situations is frequently hampered by the lingering presence of perpetrators

at the scene of the attack.

Over the course of the past two decades, the U.S. military has developed program

that has revolutionized the way in which casualties are treated on the battlefield. The

military’s tactical combat casualty care (TCCC) has been proven to save lives because its

protocols address the need to stop bleeding and hasten evacuation from sites of injury to

hospitals. TCCC doctrine is adaptable to the civilian emergency medical community

where it has applicability in the treatment of wounded people in high-threat

environments. A civilian version of TCCC, known as tactical emergency casualty care

(TECC) has gradually made its way into some public safety jurisdictions in the U.S.

TECC makes provisions for the rendering of emergency medical services in austere

environments, including active shooter events, wilderness settings, and urban

environments. A TECC program known as the rescue task force (RTF) is ideal for the

delivery of on-site emergency medical care at active shooter and terrorist incidents. In

TECC RTFs, specially trained and equipped EMS personnel enter hostile scenes under

the escort of police force protection units to treat trauma victims and evacuate them to


TECC is different from TCCC in that it makes provisions for the treatment of

children, the elderly, and the infirm in civilian domains. In addition, TECC doctrine also

takes into consideration statutory limitations and civil liability concerns that TCCC does

not. There are alternatives to the TECC RTF model. One involves specially trained police

officers providing initial emergency medical services at the scenes of active shooter

incidents and terrorist attacks. Another is for tactical medics assigned to SWAT police

teams to render these services. This thesis will demonstrate why the TECC RTF is

superior to the two alternatives.

Response to mass casualty incidents also requires hospitals that are uniquely

trained, equipped, and staffed. The nation of Israel has developed a methodology for the

effective management of casualties that occur in mass terrorist attacks, such as suicide

bombing attacks. In the Israeli model, logistics are as important as the medical

procedures that are performed on patients. Upon notification of terrorist attacks, Israeli

hospitals activate surgical teams for each patient and senior trauma surgeons quickly

diagnose patients as they arrive at emergency departments to determine which are most in

need immediate life-saving interventions. The Israeli system is adaptable to the U.S. In

the wake of the marathon bombings, hospitals in Boston were able to care for high

volumes of casualties seamlessly because they had learned Israeli hospital concepts such

as surge capacity, assigning multi-disciplinary surgical teams to each patient, and the

importance of having experienced trauma physicians monitor each victim’s progression

throughout the emergency department.3

This thesis examines four case studies to evaluate the need for the implementation

of TECC rescue task force programs and specialized hospital trauma care protocols in the

United States. 4 The case studies are the Israeli hospital trauma model, the Century

Theater shooting (Aurora, Colorado), the Boston Marathon bombings, and the Los

Angeles International Airport active shooter incident of 2013. Qualitative analysis of the

research material was undertaken in an effort to determine the effectiveness and

feasibility of military tactical emergency medical programs and their utility in the civilian

domain. Analyses of these case studies illustrate the urgent need for standardized TECC

rescue task forces and the Israeli trauma paradigm in the U.S.

The research conducted for this thesis indicates that most public safety

jurisdictions in the United States are not ready for active shooter events or terrorist

attacks resulting in mass casualties because they have not implemented TECC rescue task

force programs and Israeli hospital trauma protocols or anything as effective. The

research indicates that most public safety jurisdictions in the United States are not ready

for active shooter events or terrorist attacks resulting in mass casualties. As a result of

these systemic deficiencies, the nation is particularly vulnerable, and lives could be lost

unnecessarily due to the inability to get medical care to the wounded during high threat

situations. The TECC rescue task force model is the most optimal one to ensure that

emergency medical services are administered effectively at scenes of mass casualty

events, and the Israeli hospital model is the exemplar for definitive care.

Obstacles to the implementation of TECC rescue task forces include the high cost

of training and equipment, as well as the increased risks posed to EMS personnel.

Establishment and sustainment of TECC rescue task forces requires funding, support

from public safety officials, and joint tactical training for both police officers and EMS

practitioners. Police officers assigned rescue task forces need to provide force protection

to firefighters and EMS personnel as they enter active shooter scenes to administer first

aid. Furthermore, fire and EMS departments will need to outfit their rescue task force

personnel with basic TECC equipment such as combat application tourniquets and

hemostatic bandages. Additionally, medics assigned to rescue task forces need ballistic

protection equipment—specifically body armor and helmets—because they will be

entering high threat areas, running the risk of being exposed to gunfire and explosive


The U.S. Congress, the Department of Homeland Security’s Office of Health

Affairs (OHA), and the Federal Emergency Management Agency (FEMA) should

identify funding mechanisms that will meet the needs for TECC rescue task force training

and equipment. Possible sources of funding include FEMA’s Assistance to Firefighters

Grant (AFG) and homeland security grants such as the State Homeland Security Grant

Program (SHSP). Priority should be given to public agencies that either have TECC

programs or who are in the process of establishing them.

There is also a need for hospitals in the United States to emulate the Israeli

hospital method for treating mass casualties. The Israeli all-hazards approach works well

for any type of large-scale trauma event. In order for U.S. hospitals to provide

comprehensive care during active shooter events, terrorist attacks, and other large-scale

medical emergencies, they need to prepare to handle a high volume of seriously injured

or sick people. Funding for improvements in hospital capabilities may be available

through the U.S. Department of Health and Human Services’ Hospital Preparedness

Program (HPP), which helps communities increase medical operational capacities during



1 J. Pete Blair, and Katherine W. Schweit, A Study of Active Shooter Incidents, 20002013, (Washington, DC: Texas State University, and Federal Bureau of Investigation, 2014), 6.

2 Gary LaFree, Laura Dugan, and Erin Miller, Integrated United States Security Database (IUSSD):Terrorism Data on the United States Homeland, 1970 to 2011 (College Park, MD: START Resilient Systems Division, U.S. Department of Homeland Security, Science and Technology Directorate, (2012),, 8.

3 The Boston Marathon bombing will be the subject of one of the case studies of this thesis.

4 The case studies are on Israeli hospital trauma model, the Century Theater shooting in Aurora, Colorado, the Boston Marathon bombings, and the Los Angeles International Airport active shooter incident in 2013.


No Comments

Post a Comment