Episode 05: Casualty Collection Point and Ambulance Exchange Point

C3 Podcast: Active Shooter Incident Management

Episode 05: Casualty Collection Point and Ambulance Exchange Point

Discussion of Casualty Collection Points (CCP) and Ambulance Exchange Point (AEP) in Active Shooter Incident Management (ASIM)

Bill Godfrey:
Hello, and welcome to this next installment of talking about some of the challenges that we see on active shooter incidents. Today we are going to talk about Casualty Collection Points. My name is Bill Godfrey, a retired Fire Chief and one of the instructors at C3 Pathways. I have with me part of the Instructor cadre team, Adam Pendley, Assistant Chief with Jacksonville Sheriff's Office.
We've got Travis Cox, Lieutenant from Jacksonville Sheriff's Office, Kevin Burd, Lieutenant with the Huntington County Prosecutor's office. All three of them are law enforcement, obviously. Then also with me we've got Robert Lee, retired Battalion Chief, Paramedic and Tom Billington, also a retired Fire Chief and a Paramedic. Welcome guys, thanks for taking the time this afternoon to talk about this.
So the subject today is Casualty Collection Points, and some of the challenges, what makes a good Casualty Collection Point, what doesn't, how do we manage them, how do we work them together, how do we deal with some of the law enforcement issues and then some of the EMS issues. Adam, you want to kind of set the stage for us on what we're talking about as we move into a building.
You make entry, we've presumably dealt with the threat, or there's a team in process of dealing with the threat. But the first ones through the door are going to be law enforcement. Law enforcement officers, in some element of a Contact Team, it may just be two or three guys, or it may be four or five. Set the stage for us of what this looks like as the Contact Teams are working in the building and making a decision about where they're going to set up a Casualty Collection Point, and what they're going to pick.

Adam Pendley:
Sure. I think we're all familiar from the law enforcement perspective that there's this push towards dealing with the threats, stop the killing. But along the way, those first Contact Teams are going to identify areas where there are Casualties, where there are injured folks that need to be cared for.
It becomes important to ... whether it's the initial Contact Team that is no longer being driven by some sort of move towards the threat that they have to make a decision to go ahead and establish a Casualty Collection Point, or communicate that there's injury in a particular place and a follow on team is going to establish a Casualty Collection Point so you can quickly or simultaneously both deal with the threat and start worrying about your second priority, which is the rescue, dealing with those folks that are bleeding and need immediate care.
I think it's important for law enforcement to understand that initial team that is going to establish a Casualty Collection Point so you can make it to your next priority. I think Kevin can probably talk a little bit about what that team is going to do when they enter a room that has a number of Casualties in it that we need to move towards.

Kevin Burd:
Okay, so once we've identified in an area where we may have multiple Casualties, regardless of the tactics that are used to enter that room, once we get into that room we want to establish points of domination. They'll mention we may only have two or three officers, maybe we have four or five at this point. But once we enter that room we want to have points of domination so we can put folks that are in that room in an area that's Tactically advantageous to us.
What we're trying to look to establish is obviously securing that room, and also looking at is this room advantageous to us where we can eventually set up an Ambulance Exchange Point. Maybe that room, if it happens to have exit doors, or an exit door, some place where we can eventually get to move those patients out, we want to make sure that we've secured that entire area.
If we have multiple Casualties in that room, we're going to put them in an area where there're no issues from the law enforcement side in that we could be putting them in a position where we could have cross-fire issues where it may be near an exit door where they could possibly get away from us. We have to identify who they are first and foremost. One of the important things to remember, too, is once we establish those points of domination we have to control and secure that room and make it defensible because others will be coming in eventually to provide assistance.
When you're in that room and you're in that area, a couple of things you want to be cognizant of is what could be used against us, if you will. If there are areas where we can't secure that area, we may have to look at collapsing other Casualties in the room into our area, or possibly setting up secondary Casualty Collection Points.
But primarily the first room we go into, if we have several of the Casualties, or a majority of the Casualties there, we want to establish those points of domination, make sure that we have enough resources there, we may be calling out requesting additional resources because we want to secure that area so any follow-on resources that come in to assist us, it's completely secured.
In dealing with the Casualties themselves, I think Travis, you can touch in on that.

Travis Cox:
Absolutely. One of the responsibilities of law enforcement inside a Casualty Collection Point is to do some type of Triage of the victims or the patients that are inside that room. One way the law enforcement can do that very rapidly is basically by addressing the folks that are inside that room and asking those that can move, ask them to move to one side of the room against the wall.
Once you have that one group against the wall, you still may have some people that are injured that can't move, and they'll still be on the floor. Obviously, you're going to use good law enforcement commands, tell them to keep their hands where they can be visible for all of law enforcement to see, but you want them to move against one wall. Once you separate that group, you have one group on the ground still, and you have one group against the wall.
Once you have that group against the wall, you're going to give a second command to say those that are standing against the wall, if you're not injured, or you've not been hurt in any way, move to a separate wall ... a second wall. So now you've basically separated that room into three groups. You have the injured folks that are on the ground that cannot move, you have a second group that did move but they're injured and they're standing on one wall, and then you have a third group that has moved to a second wall but they're uninjured.
You have now did a quick Triage of that room so you can call those folks using the medical terms of the "reds" which mean people that are injured that could not move. You can even classify them as a "red patient". Those people that are injured but can move are also known as a "walking wounded." Those would be your green patients. And then your uninjured folks that you would not assign them a color, they're just people that have been involved in the incident and they have no injuries.
So you separated the people in your room into three different groups, and that's a quick way that you, as a law enforcement officer, can Triage a room and help you manage that room until your medical counterparts arrive.

Bill Godfrey:
Let me kind of summarize and see if I've got this right on what you're saying. You identify the room that you want to use, or the room that you're going to make entry to. You use some tactics, depending on their training or local policy, to do the room entry, I guess the numbers of the team affect that as well. They get in the room, they look to take control of the crowd, take control of the people that are in the room, get them up against a wall, the ones that can, screen off the ones that aren't injured so that you've got the uninjured that can't move that are on the ground.
We call those the "reds", the injured that are up against the wall that move, those are the "greens", the uninjured are on another wall. Then, what Kevin was talking about, the points of domination, to post your people up where you could control the room, control access to the room, and basically have that be a safe ... maybe the wrong word, but a reasonably safe room to work in. Am I describing that right? Did I miss anything?

Travis Cox:
Yes, you described it perfectly. What this allows you do is you can then identify people that may need medical treatment right away, and as law enforcement officers, if we have security measures in place in that room, we could then begin doing some of those life-safety measures on those folks that are injured and cannot move. So this is our opportunity to start those life-safety measures until our medical counterparts arrive.

Bill Godfrey:
So if you've got a team of four or five officers, a couple of them can hold security and a couple of them can start getting into the medical care, try to do some life-saving stuff?

Travis Cox:
Absolutely. Absolutely. That's one of the things that we're there for. Obviously, we know there's a threat in the building. Once we address that threat, our next priority is to start addressing those injured patients or those injured victims inside this crisis site.

Adam Pendley:
And I think it's worth adding that it's really not that different than typical level one training that law enforcement has received all over the country. We know that if we address a threat in a room that as soon as that threat is neutralized, you go into a SIM, a Security, Immediate Action Plan, Medical. Well, a team that may be assigned just to go to a Casualty Collection Point and secure a Casualty Collection Point is also putting together a SIM.
They get security of the room, they put an Immediate Action Plan together as far as how they're going to deal with additional injured, how they're going to sort the room, where they're going to evacuate patients from, what additional resources they need, and then they start addressing the medical. So a team that may not have addressed the threat, they may just be a follow-on team that's assigned to deal with Casualties in a particular area. They're going to put together a SIM for that room as well, Security Immediate Action in Medical.

Travis Cox:
Let me add one more thing to that, Adam. One of the critical things that those law enforcement officers are going to do when they do Triage that room in that manner, is it allows them to give the number of injuries and the type of number of injured folks that they have to the Tactical person, or that person that's on the outside that's setting up the management aspect of an active shooter response.
By doing these things, we can let Tactical know, "Hey, we have this many injured. This is how critically are they injured," and it gives them information to know how many Rescue Task Forces we may need, how many medical personnel we're going to need, how many rescue units or ambulances we're going to need, based on what we're seeing inside the crisis site.

Bill Godfrey:
So that provides us an interesting transition point to talk about it. Once you kind of get all that stuff set, you call out to Tactical and you say, "Okay, we're ready for a Rescue Task Force." So at this point we've got a law enforcement team that's inside. They've secured the room, they've got a Casualty Collection Point, if they've got enough numbers to hold security and do medical, they've started that.
We've called Tactical to say, "Here is what we've got, our location and numbers. We need a Rescue Task Force." So then the RTF goes Downrange. So, Tom and Robert, talk a little bit about that first RTF through the door that's going to dump into that Casualty Collection Point. What are their responsibilities? What do they need to do when they walk into this room full of injured? Take us through that and paint the picture.

Tom Billington:
Okay, well piggy-backing off what my law enforcement counterparts have said, right off the bat they've painted a picture for me as an RTF. Before I even get into the room, I know kind of what I'm going to be seeing. So if there's more than three patients, I know right off the bat I'm going to need another RTF, or maybe two to three more RTFs to help me.
When I enter the room with my security contingent, it sounds like as Travis said, I'm going to have personnel that are green in one area that are standing, or walking wounded, and then I'll have the other patients that are more severely injured.
Since we are the first RTF we cannot use tunnel vision. We have to get in there and start sorting and arranging which patients need to be treated, do some quick interventions while we can, some life-saving interventions, and then make sure we're setting up the room for the next RTFs to come in.
The first RTF when you get in there, if possible, you want to stay in there and kind of control the room and work with the law enforcement counterparts. That way, one person familiar with how the room is working and what patients need to be Transported, etc. Robert, what do you think?

Bill Godfrey:
Yeah, Robert, what are some of the challenges that you see the RTF teams running into and the mindsets? What are the things that people that need to be prepared for?

Robert Lee:
The first thing is we've got to make sure that our folks don't get the tunnel vision like Tom said, and concentrate on one patient. We need to scan the room. Those critically injured that we call "reds", we need to assess them, start to treat them, and prioritize them according to the severity in which ones need to be Transported. Priority opposed to the other one, so that makes sure we get the patients that need the care the soonest to the hospital first.
One of the things that a lot RTFs tend to do is they find a patient that's critical, and they start providing that care, and they don't focus on the big picture -the whole room and all the patients that we have. When the other RTFs come in, those patients that we've identified as priority, we can start providing that care right off the bat and get them ready for Transport.

Bill Godfrey:
So the coordination piece of it is huge for that first RTF coming through the door.

Robert Lee:
Yes. Yep.

Bill Godfrey:
When they ... I guess from what you're saying, one of the first things we want to see that RTF do is to re-Triage these patients. I mean, law enforcement presumably has done a dirty red/green split just to give us a sense of the bigger picture numbers. But we need to re-Triage them and is start enough, or does it need to be more than start Triage? What does that Assessment look like that needs to go on there from the Rescue Task Force?

Travis Cox:
Yeah, we need to concentrate on making sure we're doing a full Assessment of these patients once the manpower is in the room, and we've identified who we need to start with first. That full Assessment is important. Instead of just doing the Triage itself and maybe just a quick treatment, we need to do a full Assessment like we would anybody else.

Bill Godfrey:
Yeah, and I know, Tom, we've talked many, many times in a lot of the classes we've taught where the start Triage is used. I don't know about you, but I certainly seem to have run across a lot of active duty folks in the EMS community that kind of feel like ... I get the sense that they don't realize that they need to do more than start.
They think the greens can sit and wait for an hour. Tom, talk to me a little bit about some of the challenges in dealing with the severity and the different color groups, prioritizing the x-field, to whose going to go first, the mix of severities, and the implications for that for our ambulance loading.

Tom Billington:
In this situation we're dealing with trauma, gunshots usually. Right off the bat we need to decide which gunshots need surgical intervention as soon as possible. We need to be able to decide which patients we want to treat and Transport first. The other issue making sure that although some patients may be listed as green, remember, that may change. The numbers will continually change.
The main thing is just making sure you're communicating with Triage about what hospitals you can utilize, what care various patients are going to need, a chest would versus a head wound, depending on the facilities you have, and being able to coordinate those patients out accordingly.

Bill Godfrey:
One of the things that I hear are Tactical and Triage, and Transport group supervisors talk about frequently in the scenarios that we run, is their frustration that they don't feel like the RTFs necessarily are giving them the information they need. They're not very quick to relay it to them how many reds, yellows, and greens they have. How many black tags.
Again, it is difficult with a moving target, because the numbers ... As you begin to move patients out to Transport, law enforcement may be bringing some additional patients in. You may have a green that goes to a yellow, or a yellow that goes to a red. It is going to be a moving thing. What is the best practice for RTFs? What should be expecting from the RTFs in terms of keeping Triage informed of the numbers? When do they do that, and how often do they need to redo that?

Tom Billington:
Well obviously when we get into the room we want to double check on the counts that law enforcement gave us, and then do a thorough Triage again, and make sure they're color coded correctly. That would be a good time to let Triage know what we have and what color type patients we have. Again, remembering that by the time they get to the ambulance, the ambulance may have to change those color tags with Transportation so Transportation will get a good number at the end.
Again, just keeping the number as fluid as possible, keep getting the information going. Again, that's another reason why the first RTF in the room may want to be the primary room proctor, stay there, and be able to monitor the patients as they change and add numbers or change numbers accordingly.

Bill Godfrey:
Tagging on to what you're saying about that, Tom, one of the things that we talk about in class sometimes is the Field Triage Score, which of course was a Triage system validated in a military study. Basically, it has two measurement points. You check the Radial pulse. If it's present and it's normal, they get one point. If it's absent, it's weak, thready, tachycardic, they get zero. Then you check your Glasgow Motor Score, not the whole GCS scale, just the motor score. Basically, do they obey commands. If they obey commands, they get one point. If they don't obey commands or are unable, they get zero. You add it together, zero, one, two, red, yellow, green.
It's a nice, simple system, again, validated in a military study. It gives us some sense that it's a good, quick, easy way to get a good Triage of the patients that we're moving. So we get these patients packaged up, let's assume that we've got more patients that one RTF is going to handle, and we've got two or three other RTFs that are coming into the room. What role, Tom, does the first RTF need to take on in relation to the other ones coming in, or is it just a free-for-all, they all come in and take their own patient?

Tom Billington:
As I discussed earlier, that first RTF is sort of the lead, and hopefully they will be staying there for the duration. When the next RTF comes in, that lead wants to look at the RTF leader and the medical leader, and say, "You two go over there. You have this. You have that. You have a red. You have this injury. You take care of that." When the next RTF comes in, same thing. So you're kind of coordinating the whole operation. Again, making sure that if it's a red, which red do you want treated first? Which one needs that surgical intervention? Again, being in charge of that room and being able to direct the medical resources when they come is imperative.

Bill Godfrey:
So we get them lined up, we know whose going to go first, we kind of lay them out in order in the room, then we've got to coordinate the evacuation over to the Ambulance Exchange Point. Of course, the challenge there is we want to get the ambulance as close as we possibly can, but that kind of creates some security issues for it, doesn't it?
What are we ... So we're back over to the law enforcement side of this in having to kind of coordinate our movements and behavior. What does that look like when we say, "Hey, we want to use this exit door over here that goes right out to the parking lot as our Ambulance Exchange Point."

Adam Pendley:
Well I think it's important to keep in mind that there is a security element with the RTFs, and they remain there the whole time. Again, their first priority is to provide that security element for the folks that are doing the medical care, but they also have communication with Tactical, so if there is a particular door that based on its location looks like that it would lead out to a good Ambulance Exchange Point, the security element can communicate with Tactical, and make sure that that area is secure so you can use that space efficiently.
But I also feel like it's important to remember that if the security element of the room is doing its job, and there are extra law enforcement resources available, so much of law enforcement across the country has received additional training on some direct threat care, and may be able to assist with the medical element as well. So, there's a lot of resources in that room, but everyone has to realize that it is an integrated, cooperative response to make sure that the room is sorted, that the room is Triaged, and that medical care is happening, and when the RTFs are ready, that secured ambulance exchange points are happening.
It's kind of a continuum of care that starts from the point at which law enforcement initially makes entering into that room, sorts the room, communicates to Tactical and Triage the numbers that they have. RTFs are brought into the room to start the medical care, and then continuing with law enforcement, there's a good security element to move them out to an Ambulance Exchange Point that would also coordinate with Transport that's there with Triage and Tactical so ambulances can come Downrange and get people to the hospital as quickly as possible.

Travis Cox:
If I can add to what Adam said, which is very important, you know a lot of us in emergency services and law enforcement, we have that built-up immunity where we try not to get too involved, and there's people bleeding around us that sometimes we have to step over them.
But when the killing has stopped, [inaudible 00:22:32] is so important in law enforcement can save so many lives and help with the medical as far as just putting that tourniquet on and just getting the position where the patient can breathe just until they get more intervention. So, a lot more lives can be saved working together. Adam, good point.

Bill Godfrey:
Yeah, so we get them packaged up, we figure out where we're going to do our Ambulance Exchange Point. Assuming that you're spread too thin on the inside, who's going to take care of getting security over the Ambulance Exchange Point? How does that play out?

Tom Billington:
Well, one of the things that needs to happen, is there needs to be good communication to whoever that medical leader on that Rescue Task Force is, speaking with the law enforcement element within that Task Force so that medical person needs to give a heads up to the law enforcement counterpart, "Hey, we'll be ready to move in two to three minutes."
That's the que for law enforcement to start communicating with Tactical, whose managing everything moving in the warm zone to start setting up that security perimeter around where the Ambulance Exchange Point's going to be. Again, also that law enforcement security personnel on the inside needs to request the location from Tactical because the location that they want to use as the Ambulance Exchange Point may not be the most optimal spot based on the information that Tactical has.
So, if the place where the rescue responders on the inside want to use as the Ambulance Exchange Point is a viable location, then they'll set up security there. If not, they may have to re-route them. They may have to go to a different location for reasons not known to them.

Bill Godfrey:
So, Kevin-

Kevin Burd:
Yeah.

Bill Godfrey:
Paint the picture on the Tactical side. Let's say we're dealing with a school, two, three story building, we're going to use an exit door on the rear side of the school. What does that Contact Team that gets sent to secure the Ambulance Exchange Point ... what do we want them to do? What do they need to be looking for? What's their job? What does that look like?

Kevin Burd:
Really, what we're looking for, again, just like the room management part, the room security part, is to provide almost like a security bubble, if you will, outside that door where we've determined this is going to be the Ambulance Exchange Point. We're looking for that 360 or 540 degree coverage, and want to ensure that we have unimpeded egress for the ambulances to get into that location. It almost has to be a ballet act, if you will.
We are looking for communication coming from the RTF, or the medical team leader, that "Hey, we're ready to move patients in two or three minutes," the law enforcement counterparts are ensuring that, "Hey, we've got security at the Ambulance Exchange Point." We don't want to put the Casualties out in an area where they're waiting for an extended period of time for those ambulances to come.
So, we want to ... like that ballet act, if you will. The RTFs are moving the patients down to that Ambulance Exchange Point, security is making sure that, "Hey, it's safe to come outside," the ambulance at the same time is coming up, and it's a coordinated effort between all the disciplines to get the patients on to that ambulance as quickly as possible, as safely and securely as possible, and off to more advanced medical care.

Bill Godfrey:
You know, it's interesting. I think your comment about it being a ballet is really an appropriate way to think of this. It's very much an integrated piece on how we all have to work together. Law enforcement has that initial role to kind of get control of the room, set up the security, do some initial Triage, even if it's just a gross Triage to split the room between the walking wounded injured and the ones who can't move, make it a warm zone so that we can get a Rescue Task Force in.
They can come in and re-Triage, do some ... whatever emergent advanced stabilizing care they need to, and then coordinate a place that the ambulances are going to come pick them up. It is very much a ballet, but the winning part of that is we take time off the clock. It saves time, and that's our goal is not just to put the bad guy down quickly, but also to take time off that clock for the people that have been shot and bleeding, and get them into the back of an ambulance faster.
So I love your analogy of the ballet, and I think like this, if you practice and train it, and beautifully orchestrate it, it is something that can really make a difference and save lives. Well guys, thank you. I think you really did a nice job of painting the picture for the process of a CCP, and kind of crossing over to the other [inaudible 00:27:15]. Thanks for taking the time this afternoon. Take care, and we will talk to y'all soon.
Original Source: https://www.c3pathways.com/podcast/casualty-collection-points-and-ambulance-exchange-points