Originally published in the New York Times
WASHINGTON — Seven minutes after the authorities in Sparks, Nev., received a call one day in October that a gunman was on the loose at a local middle school, a paramedic wearing a bulletproof vest and a helmet arrived at the scene.
Instead of following long-established protocols that call for medical personnel to take cover in ambulances until a threat is over, the paramedic took a far riskier approach: He ran inside to join law enforcement officers scouring the school for the gunman and his victims.
“He met the officers right near the front door, and they said: ‘Let’s go. There are victims outside near the basketball court,’ ” said Todd Kerfoot, the emergency medical supervisor at the shooting. “He found two patients who had been shot and got them right out to ambulances.”
Federal officials and medical experts who have studied the Boston Marathon bombing and mass shootings like the one in Newtown, Conn., have concluded that this kind of aggressive medical response could be critical in saving lives. In response to their findings, the Obama administration has formally recommended that medical personnel be sent into “warm zones” before they are secured, when gunmen are still on the loose or bombs have not yet been disarmed.
“As we say: Risk a little to save a little, risk a lot to save a lot,” said Ernest Mitchell Jr., the Federal Emergency Management Agency’s fire administrator, who released the new guidelines on mass casualty events for first responders in September.
The guidelines say that such events, which have led to more than 250 deaths in the past decade, are “a reality in modern American life” and that “these complex and demanding incidents may be well beyond the traditional training of the majority of firefighters and emergency medical technicians.” They recommended that any of those first responders sent into “warm zones” focus on stopping victims’ bleeding.
The guidelines also say that first responders should be equipped with body armor and be escorted by armed police, a policy that officials in Sparks and a handful of other cities had already adopted.
The new focus on moving faster to treat victims follows an earlier shift in thinking about how quickly the police should respond.
In the 1999 shootings at Columbine High School in Colorado, where two disaffected students killed 13 people, no officers entered the school until a half-hour after the shooting began and SWAT teams arrived to respond to a highly planned attack that involved a fire bomb and other explosive devices.
After Columbine, law enforcement officials made it clear that they wanted the first officers on a scene to act immediately instead of waiting for specially trained officers with body armor and high-powered weapons.
“These events like the shootings are usually over in 10 to 15 minutes, but it often takes over an hour for everyone to get there,” said Dr. Lenworth Jacobs, a trauma surgeon who created the Hartford Consensus, which brought together experts in emergency medicine and officials from the military and law enforcement after the Newtown shooting to determine better ways to respond to mass casualties.
“We’re seeing these events in increasing frequency, and unfortunately we have to change how we approach them to keep death tolls down,” Dr. Jacobs said.
While the United States military saved thousands of lives in Iraq and Afghanistan by practicing combat medicine developed over years of responding quickly to battlefield injuries, the medical response to the bombings last April at the Boston Marathon provided a dramatic example on American soil of how lives could be saved by acting quickly.
The bombs went off near the marathon’s finish line, where many nurses and doctors were stationed to care for injured or ill runners and major hospitals were not far away. The bombing victims received medical assistance almost immediately, and while three people were killed, more than 200 others who were injured survived, including a dozen or so who had limbs amputated.
Those medical professionals were taking a risk: They did not know how many bombs there were or whether they were putting themselves in the middle of a larger attack.
The new FEMA guidelines have been embraced by state and local officials. But they have heightened concerns about the risks to first responders and about whether response times for victims would grow even longer if medics were wounded in a danger zone.
They have also raised the specter that terrorists may target the first responders as they have in Iraq. In recent years, the Qaeda affiliate there has in many instances detonated a car bomb and then, as medical personnel arrived, set off others.
But Harold Schaitberger, who leads the International Association of Fire Fighters in Washington, said his organization played a role in creating the new guidelines and strongly supported them if employed correctly. The association represents 300,000 firefighters, paramedics and others.
Trying to save victims in “warm zones,” Mr. Schaitberger said, “is a different risk for firefighters, but not more of a risk than firefighters already take in responding into a burning structure.”
Mr. Mitchell, the fire administrator, said the gunmen and terrorists who mounted attacks in the United States over the past decade rarely made targets of first responders. But, he said: “We know that this possibility does exist, and part of the training of the fire and E.M.S. is to be observant and aware and to be on the look for suspicious activity and so forth.”
Other efforts have focused on educating civilians on the need to react quickly to danger.
This year, many police departments began education efforts that urged anyone caught in a mass shooting to “run, hide or fight” instead of waiting for help.
After all, the people at the scene can often stand in for first responders before they arrive.
“In Boston, you saw that the public didn’t run,” Dr. Jacobs said. “You need for the public to have the most education about how they can help to improve the survival results.”
<img src="http://meter-svc.nytimes.com/meter.gif"/> A version of this article appears in print on December 8, 2013, on page A1 of the New York edition with the headline: In Mass Attacks, New Advice Lets Medics Rush In.