The number of lone actor terrorist attacks has increased in recent years. These have taken the form of bombings, shootings, stabbings, the deployment of chemical or biological agents, and the use of vehicles as a weapon. The medical response to such attacks primarily involves patient care once the incident is over. However, in the case of lone actor attacks that take the form of an active shooting, a modified response by Emergency Medical Services (EMS) providers may allow for treatment of some victims before the scene is fully secured. Two recent active shooter incidents in Pennsylvania, the West Nickel Mines Amish school shooting and the Kraft Foods plant shooting in Philadelphia, are presented with a description of medical issues encountered. The Rapid Assessment Medical Support (RAMS) program, developed by the Philadelphia Fire Department and the Philadelphia Police Department based on lessons learned from these and other such incidents, is one way that EMS providers can initiate patient care at active shooter incidents in areas that have been cleared by police but not secured. It is based on the premise that care of victims is a shared responsibility of police and EMS. It involves close coordination and ongoing training between the two departments with a priority given to early hemorrhage control, airway management, patient evacuation away from the immediate threat, and rapid transport to a trauma center. The RAMS program represents one way to potentially save lives during lone actor attacks.
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