Truly Resilient Communities:
Chief Rob Wylie (ret), BS, EMT-T, EFO
What is a resilient community? According to the Community & Regional Resilience Institute, resilience is “the ability to anticipate risk, limit impact, and bounce back rapidly through survival, adaptability, evolution, and growth in the face of turbulent change”.
As a 30 year veteran of the fire and emergency services, the holy grail has always been for me to assist the communities I served to become resilient: To prepare for natural disasters such as tornadoes, floods and fire; to have individuals and groups (neighbors) be able to stand on their own for a period of time until the fire department can get to them, especially during a disaster.
To that end we have spent countless hours and hundreds of thousands of dollars training people in things like CPR, and basic first aid, but the basic underlying premise had always been: “We (the FD) are coming, and when we get there get out of our way”. The issue with the “I will just call 911 and a police officer, firefighter or medic will magically appear and solve my problem” is that it really doesn’t work that way.
When attendees at a recent First CARE Provider class I taught were asked; “what do you do in an emergency”? The answer was unanimous: Call 911! When the same group was asked “how long do you think it will take a responder to get to you after you call 911”? The most popular answer was 5-7 minutes (fig. 1).
The dirty little secret that no one wants to address is that it takes as little as three minutes to bleed to death from a traumatic injury. It takes time for responders to be notified and to make their way to the scene of the emergency. When someone is dying, time is a matter of life and death.
While 5-7 minutes is certainly an acceptable response time for emergency responders in many communities, in other communities like Barrow Alaska, where my colleagues and I recently taught a First CARE Provider class, the response time could be hours or days depending on such variables as weather and distance. The North Slope Fire District is responsible for over 90,000 square miles!
And while Barrow represents an extreme example of prolonged response times for emergency responders, in fact, even in a metro or suburban area response times can vary greatly depending on the scope of a disaster, the number of emergency calls resulting from that disaster and the number of responders available at any given time. The International City Managers Association (ICMA) set the acceptable rate of emergency responders at about 1 responder for every 1000 residents. That translates to very few responders when a major incident occurs like a tornado or a hurricane.
As I mentioned previously, we spend hundreds of hours and thousands of dollars training people in CPR, how to use and automatic external defibrillator and basic first aid. The fact of the matter is this: An American Heart Association report suggests the incidence of out-of-hospital cardiac arrest is 326,200 annually. The average survival rate is 10.6% and survival with good neurologic function is 8.3%. http://www.sca-aware.org/sca-news/aha-releases-2015-heart-and-stroke-statistics
Compare those statistics with those that list trauma as the #1 cause of death in people between the ages of 1-45 years of age, with an economic impact annually of 400 billion dollars, of which 20% are considered to be survivable with proper intervention and you are looking at 30 thousand live saved annually. (Fig2)Survivable injuries include bleeding to death (exsanguination). Uncontrolled post-traumatic bleeding is the leading cause of potentially preventable death among trauma patients 
In fact, if proper interventions are done within the first 3-5 minutes for such injures as critical bleeding, there is a 90% chance that the injured person will survive.
With that in mind, we get a much bigger “bang for the buck” teaching civilians to use tourniquets than we do teaching CPR.
Before the hate mails starts, I fully support teaching CPR. It saves lives. But a broader, more comprehensive approach is needed.
To build truly resilient communities we first have to dispel the myth that emergency responders will solve all our problems. We must acknowledge that for the first 5-7 minutes in an emergency the true first responders are the people who are present at the time of the incident.
Teaching those First Care Providers to deal with traumatic injuries such as critical bleeding will save lives and empower those who receive the training to make a difference rather than just calling 911 and hoping help arrives in time. One thing I have learned over the past30 years is that hope is not a plan.
I am not advocating that people sitting at home see or hear a story about a bus accident and leap from their chairs to go render aid. I am talking about teaching the people who may be on that bus sitting next to their child or spouse or friend to act and to save that loved one’s life.
We as emergency responders have to get past the idea that we are the only ones who can help in these situations: Civilians with a modest amount of training can make a difference when it comes to traumatic injuries such as critical bleeding (tourniquets and wound packing), airway obstructions(recovery position) and breathing problems resulting from trauma (chest seals).
Through a series of exercises held during First Care Provider training sessions we have found that average people with as little as a half day of training are almost as effective as trained responders in recognizing critical issues like bleeding, and intervening .
In summary; to be a truly resilient community we much teach people how to rely on themselves in the critical first five to seven minutes it takes for the even the most robust response systems to reach the victims of traumatic injury. First responders have to start looking at their residents as force multipliers instead of hapless bystanders that need to be moved out of the way during an emergency. As emergency responders we have to pop the illusion that we will always be there in time to make a difference. We have to acknowledge and prepare of citizens for the reality that in a time of a wide spread crisis like an earthquake, a tornado, severe weather or even the fact that we have large areas to cover and not enough resources to cover them all in that five to seven minuet window, that with a modest amount of training those that are first there can provide meaningful and effective first care.
 World Health Organization: cause-specific mortality and morbidity. http://www.who.int/whosis/whostat/EN_WHS09_Table2.pdf
Cothren CC, Moore EE, Hedegaard HB, Meng K. Epidemiology of urban trauma deaths: a comprehensive reassessment 10 years later. World J Surg. 2007;31:1507–1511. doi: 10.1007/s00268-007-9087-2. [PubMed] [Cross Ref]
About the Author:
Robert B. Wylie
Chief Wylie has been in the fire service for 30 years serving first as a volunteer firefighter and then as a career firefighter, rising through the ranks to become the Fire Chief of the Cottleville FPD in St. Charles County, MO in 2005. He is a graduate of Lindenwood University (84’) The University of Maryland Staff and Command School (96’) and the National Fire Academy’s Executive Fire Officer Program (2000).Type your paragraph here.
Becoming the Agency of First Resort
Chief Rob Wylie
Emergency services, and the fire service in particular, are well known institutions in most civilizations. But what do people really know about us? The short answer is that they know what they see on TV or the internet. They know we fight fires and provide EMS and rescue services. They know they trust Firefighters as a group, in fact a 2009 poll conducted by market research institute GfK, found that firefighters ranked as the most trusted profession in Europe and the United States with 92 percent of respondents finding them trustworthy.
But what is behind the headlines and the flashy video images? What else do we offer our citizens, our “customers”? As a matter of statistics, most people never have contact with the Fire Department during an emergency. In fact, the average person will only have to call 911 once or twice in their lifetime.
So what does that mean in terms of the original question; what do our customers know about us?
The Cottleville Fire District has 40,000 residents. We run, on average, 3,500 calls for service a year. That means that if the only way we connect with our residents, our customers, is through emergency response, we are only making contact with .08% of our residents. That is not going to cut it when it comes time to ask for additional funding to meet rising costs, technology and equipment updates and the ability to provide a ready, trained and professional response system.
Let’s face it; we are in sales. Our product is safety and if only .08% of our potential customers are aware of our services and our product, we are not going to be around very long!
We are competing every day for the tax dollars our community provides, and those dollars are getting harder to come by. So the real question is not what does our community know about us, but rather how can we educate our community about what we have to offer them.
This is not as simple as holding an open house (though they are great!) or getting a few new articles out about emergency calls or checking your smoke detector regularly. If you truly want to position your department as that agency of first resort in your community, then there is some rough ground to plow to set the stage: First, you need to get your house in order. There has to be buy-in up and down the chain of command. We started by having all of our members take a values survey (Rokeach survey is excellent). This set the pace for understanding our own organizational values, what we thought of ourselves and what we determined to be important.
The next step was to reach out to the community and shout from the mountain tops “We are here to help you with any problem, or issue”. This meant having our members join the Rotary Club, the Lion’s Club, the Chamber of commerce and offering to speak to anyone who would give us 5 minutes to tell our story. That story was “we are here to help”.
If we come across someone with a flat tire, we stop and help. Mom with three kids wrestling a grocery cart across the parking lot, we are there to help. If you are having a fundraiser or a neighborhood event, we want to be there! Don’t know where to find an electrician to fix your smoke detector, we have a list! Need someone to help you navigate the bureaucratic morass of the building permits of special event permitting process, we can help!
The simple goal is to have the members of the community consider us as their go to place for assistance, no matter the topic or the issue, the Fire Department!
Keeping it going:
It really becomes a landslide of support and effort to develop sell, and then maintain this status of “Agency of First Resort”. To keep the troops leaning forward takes constant effort. You have to support them and reward them for taking on this huge endeavor. I don’t mean buying them things (although a nice lunch for a job well done goes a long way). I mean recognizing their effort and praising their work. If a resident passes along a compliment, make sure the crew hears it. The most important component of all is getting the input of those providing the service! Listen to them, support their ideas and let them run with them. They won’t all be home runs, but most will! I have found that if you take care of the people that take care of the people, they will amaze you with their caring and their innovation.
The proof is in the pudding. Sooner or later we all have to go to the powers that be and ask for additional funding. Whether it’s a levy increase before voters (customers), a municipal budget request or a volunteer department trying to increasing fire tag rates, expenses rise and revenues contract. When that time comes which camp do you want your citizens to be in? The one where people can easily say “I have never had to call them and my money is tight” or “I support whatever they need because frankly, I don’t know what I would do without them”
Think of becoming the agency of first resort as paying it forward. Yes it is our jobs to serve, but the level of that service and the commitment of those providing that service is the key to becoming an integral part of the community you protect.
The “Tactical” First Responder
By Chief Rob Wylie
Medics stabbed in San Diego and Detroit; Firefighters held hostage in Georgia; Firefighters shot at in Florida, shot and killed in Arkansas. Every week there is another story in the news about a first responder who is attacked, assaulted and even killed while preforming their duties.
This escalating spiral of violence is the new reality for fire and EMS. We are no longer immune to violence directed at responders. Gone are the days when we all believed that everyone is happy to see us, the guys in the white hats riding in to save the day.
This new reality requires a new mindset; a “Tactical” mindset.
For most of us, our academy experience taught us to always be conscious of scene security issues. Unfortunately those scene security issues were limited to live electric lines, gas leaks and the occasional OBS patient who didn’t want to hurt us, they were just under the influence of drugs or alcohol.
Meanwhile, on the other side of the building, our brothers and sisters in blue were being taught that everyone you encounter represents a potential threat. They were taught how to maintain situational awareness and to see a person’s hands at all time because their hands will hurt or kill you.
It’s time we started to bridge that knowledge gap with Fire and EMS providers. We need to teach our people to be tactical, to view every call through a lens of survival.
Believe it can Happen:
This starts with mental preparedness. I tell students all the time that first and foremost you have to believe that this can happen to you. On any given day you will encounter someone who is capable and willing to harm you for no other reason than the fact that you are in uniform. If you don’t acknowledge this fact you will not take the steps necessary to maintain situational awareness and see the trouble before trouble sees you. The signs of trouble are almost always there if you are open to the idea that it can happen today, it can happen to you and you have a plan to react.
Have a Plan:
Once you have adopted the concept that you can be the intended target of violence, you should start pre-planning your response to violence directed towards you or your crew. We call this “Hanger Flying”. Discuss the what-ifs. Talk through different scenarios and how you will react, develop a plan of action.
Visualization is an excellent way to prepare for an event. Studies show that the act of thinking through a scenario will increase your proficiency and produce a more reliable outcome than just waiting until something happens and making up a plan on the fly. In an article for Sport Psychology Today entitled The Power of Visualization, author Matt Neason wrote “What happens out there is a result of what happens in here”. In simple terms, this means your performance is often the result of what’s happening inside your head, or more specifically the movies and soundtracks playing inside your head”
The alternative is to rely on the odds that you will do the right thing in a time of extreme stress and intensity, and those odds are not good. In fact they are about 1 in 3. Many people believe that in times of extreme danger and stress that they “Rise to the Occasion”. In truth, most people instead of rising to the occasion, fall to the level of their training and preparation. Extreme stress creates what Col. David Grossman in his book (1) refers to as “Condition Black”. Increased heart rates, respirations, blood pressure and adrenaline dumps that result in decreased fine motor skills, narrowing of vision and auditory exclusion. In short you are not thinking, you are reacting. If you have trained your mind and body though visualization, physical conditioning and training, you will react more predictably and your chances of surviving go way up.
Develop an emergency evacuation plan for use when a problem develops (Ex Fill) that includes a code word for your crew as well as a rally point to meet up after you get out. Never enter a structure without identifying at least two ways out in case it hits the fan and you cannot leave the way you came in. Identify things that you have carried in, or that are available in the space you ae working in that can be used as weapons should you have to fight.
Practice the Plan:
You have accepted that fact that violence can happen to you, and you have developed a plan to maintain situational awareness and respond to violence. Now you have to practice the plan. Incorporate it into your daily routine so it becomes as automatic as checking your gear in the morning when you come on duty.
Make it a habit to check for two ways out of every structure you enter. Assign someone to keep an eye on your environment while the rest of the crew is doing their jobs. Watch for signs of aggression from both patients and by standers. Have an emergency ex-fill plan in case things go bad including a code word that everyone knows and a rally point after ex-fil so you can account for all your crew members. Look for weapons, see people’s hands and understand what you department’s policies are regarding not entering a scene or leaving if you encounter or perceive a threat.
Mental preparation, planning and practice will create a Tactical mindset that will help you identify threats before they materialize or to respond effectively if they do. Some may consider this way of thinking a bit paranoid, but you know what they say: You’re not paranoid if they are really after you!
(1) Grossman, Dave and Loren W. Christensen. On Combat: The Psychology and Physiology of Deadly Conflict in War and Peace. 2nd ed. PPCT Research Publications, 2007.
by Dr. David K. Tan
Rescue Task Force is best medical response to an active shooter incident
The EMS providers on the RTF focus on care of the victims while tactical medics focus on needs of the SWAT team
Nearly six years after Arlington County Fire Department introduced the modern concept of the Rescue Task Force (RTF) model for emergency medical response to active shooter incidents, many agencies have yet to even discuss the topic, let alone begin training their personnel to mitigate this ever-increasing threat in our communities. A common reason offered for this lack of planning is, "Well, we have SWAT medics with tactical EMS training in our area that will respond."
Tactical Emergency Medical Support, or TEMS or SWAT medics, is certainly one option for managing multiple casualties in a high-threat environment, but having it as the only option for your community is less than optimal for two important reasons.
1. TEMS is for the SWAT team
The focus of TEMS providers is on the overall health and well-being of the SWAT team itself. Their mission is to protect the protectors by being immediately available for downed officers and to provide medical intelligence that may be of tactical value to command staff.
2. TEMS providers are a SWAT asset
Tactical medics do not deploy independently. They are a SWAT asset under SWAT command with a typical SWAT response time that far exceeds the typical duration of active killing that occurs during such incidents.
Rescue Task Force
The RTF model focuses on the needs and care of the victims of a mass shooting. RTF providers work with the first-arriving patrol officers to deliver immediate medical intervention for readily treatable injuries, like severe bleeding and airway compromise, which stabilizes victims for evacuation to definitive care.
RTF providers do not wait for police to secure the scene while victims lay bleeding to death inside the perimeter. They respond with police into the warm zone to find victims, even as other officers search for and neutralize the suspect.
Both TEMS and RTF have their place in the continuum of medical care when it comes to acts of active violence, but we must begin focusing on wider acceptance of RTF integration into police response to make any meaningful impact on morbidity and mortality when active shooter incidents occur.