5.4 Protocols 25, 27, 29 & 39: Behavioral, Penetrating Trauma & High-Threat Scenes

5.4 Protocols 25, 27, 29 & 39: Behavioral, Penetrating Trauma & High-Threat Scenes

Quick Answer: Specialized high-threat protocols integrate medical triage with acute scene safety doctrine. Under Protocol 25 (Psychiatric / Mental Health / Suicide Attempt / Abnormal Behavior), EMDs evaluate weapon accessibility, active self-harm, and violent agitation while applying verbal de-escalation and mandating police staging. Its highest codes are 25-D-1 Not alert, 25-D-4 DANGEROUS hemorrhage, and 25-D-5 Near hanging, strangulation or suffocation with difficulty breathing; threatening suicide without an attempt is 25-B-3, and the scene-risk suffixes are V (violent), W (weapons), and B (violent and weapons). Protocol 27 (Stab / Gunshot / Penetrating Trauma) prioritizes central penetrating wounds (head, neck, torso, groin — coded 27-D-4) over peripheral trauma (27-B-2), and carries mechanism suffixes G gunshot, S stabbing, I impaled currently, P penetrating wound (not impaled now), X self-inflicted gunshot, and Y self-inflicted stab wound. Protocol 29 (Traffic / Transportation Accidents) identifies high-acuity mechanisms of injury—such as ejections, rollovers, extrication entrapment, and vehicle fatalities—to mobilize trauma system resources. Finally, Protocol 39 (Active Assailant — Shooter), introduced in MPDS v13.3, provides lifesaving Run, Hide, Fight coaching, enforces telecommunicator silence shielding, and coordinates Rescue Task Force (RTF) medical deployment in warm zones. Its police-service counterpart is PPDS Protocol 136; MPDS Protocol 34 is Automatic Crash Notification (A.C.N.), not an assailant protocol.

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High-Threat Operational Doctrine: Clinical Urgency vs. Scene Safety

In standard medical dispatch, the EMD focuses purely on clinical assessment and life-saving pre-arrival instructions. However, in behavioral crises, violent penetrations, vehicular collisions, and hostile acts, the incident environment itself is inherently dynamic, unstable, and hazardous. The universal operational doctrine dictates:

$\text{Scene Safety} \ge \text{Patient Care}$

The Mandatory Staging Doctrine

Responders cannot render aid if they become casualties. When a call involves active physical violence, firearms, edged weapons, volatile behavioral agitation, or hazardous materials, the EMD must immediately enter a "Stage for Police" directive into the Computer-Aided Dispatch (CAD) record:

• Staging Parameters: Fire and EMS units must proceed to the general vicinity but remain outside the line of sight and weapon range (typically two or more blocks away, staged behind hard cover) with emergency lights and sirens turned off.
• Police Clearance: Medical crews will not cross the staging perimeter until Law Enforcement on scene explicitly broadcasts that the area is secure and cleared for medical entry.

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Protocol 25: Psychiatric / Abnormal Behavior / Suicide Attempt

Protocol 25 governs behavioral crises ranging from acute depression and psychosis to violent self-injury and active suicide attempts:

1. Interrogation Priorities: Weapons & Self-Harm

The EMD must rapidly identify two critical operational elements:

• Weapon Access: "Does he/she have a weapon? What kind of weapon? Is it in their hand or accessible nearby?"
• Active Self-Harm: "Has he/she already done something to hurt themselves?" (e.g., severe lacerations, toxic ingestion, hanging, firearms).

                         PROTOCOL 25 DECISION ARCHITECTURE
                                        |
                    ACTIVE SELF-HARM / SUICIDAL CRISIS
                                        |
         +------------------------------+-----------------------------+
         |                                                            |
   WEAPON PRESENT?                                           METHOD APPLIED?
"Firearms, knives, ligatures"                              "Overdose, laceration, hanging"
         |                                                            |
   STAGE FOR POLICE                                           DELTA DISPATCH
(EMS waits at perimeter)                                  (Parallel ALS + Police)
         |                                                            |
         +------------------------------+-----------------------------+
                                        |
                          TELECOMMUNICATOR DE-ESCALATION
                         (Voice modulation & persistence)

2. Excited Delirium Syndrome (ExDS)

A critical clinical presentation within Protocol 25 is Excited Delirium Syndrome (ExDS), characterized by extreme agitation, hyperthermia (patients often strip off all clothing in public), continuous shouting, paranoia, unexpected physical strength, and complete indifference to physical pain. ExDS is a life-threatening medical emergency carrying a high risk of sudden metabolic collapse, severe acidosis, and sudden cardiac arrest. Paramedics must prepare for immediate rapid sedation (e.g., ketamine) and aggressive advanced airway management under police protection.

3. Telecommunicator Verbal De-Escalation

When handling an acutely agitated or suicidal caller, the EMD acts as the emotional anchor:

• Voice Modulation: Speak with a calm, lower-pitched, steady, and unhurried vocal cadence. High-pitched, rapid speech amplifies caller panic.
• Delusion Management: Never validate, agree with, or reinforce psychotic delusions or hallucinations; equally, never argue, mock, or attempt to debate the reality of their perceptions. Maintain grounded neutrality: "I understand you are seeing those things and it sounds terrifying, but I am here with you right now and I am going to make sure help arrives safely."
• Repetitive Persistence: Keep suicidal individuals engaged in continuous dialogue. Instruct them to place weapons on a table and step away into another room. Never abruptly disconnect.

Protocol 27: Stab / Gunshot / Penetrating Trauma

Protocol 27 manages penetrating mechanical trauma resulting from firearms, knives, shrapnel, and impaled objects. Triage is governed by the anatomical location of the wound:

Central vs. Peripheral Penetrating Trauma

+-------------------------------------------------------------------------+
|                    PENETRATING TRAUMA ANATOMICAL TRIAGE                 |
|                                                                         |
|   CENTRAL WOUNDS (DELTA Level 27-D-4):                                  |
|   - Head, Neck, Chest, Abdomen, Back, Pelvis, Groin                     |
|   - High velocity cavity collapse, hemothorax, cardiac tamponade        |
|   - Immediate Level 1 / Level 2 Trauma Center ALS activation            |
|   - Other DELTA codes: 27-D-1 Arrest, 27-D-2 Unconscious,               |
|     27-D-3 Not alert, 27-D-5 Multiple wounds, 27-D-6 Multiple victims   |
|                                                                         |
|   PERIPHERAL WOUNDS (BRAVO Level - Protocol 27 has NO CHARLIE):         |
|   - 27-B-2 Known single PERIPHERAL wound                                |
|   - 27-B-3 SERIOUS hemorrhage                                           |
|   - Extremities distal to axilla and groin                              |
|   - Risk of major vascular transection (femoral, brachial)              |
|   - Managed with immediate aggressive hemorrhage control (Tourniquets)  |
+-------------------------------------------------------------------------+

• Central Wounds: Penetrating trauma to the torso or neck creates massive internal kinetic energy dissipation. Bullet cavitation lacerates major vessels, causes pericardial tamponade, tension pneumothorax, or catastrophic intra-abdominal hemorrhage. Internal bleeding cannot be controlled in the field; the patient requires emergent surgical damage control.
• Peripheral Wounds: Limb injuries carry the risk of arterial transection (brachial, femoral, popliteal). If bright red spurting or uninhibited continuous bleeding is reported, the EMD immediately instructs the caller to apply a commercial tourniquet or improvise one high and tight above the injury.

Critical Pre-Arrival Instructions for Penetrating Trauma

• Direct Firm Pressure: Instruct the caller to place a clean, dry cloth directly over the wound and push down with maximum continuous pressure. Never remove saturated cloths—apply additional layers directly over the old ones to preserve nascent clotting factors.
• Impaled Objects: "Do not remove the object! Leave it completely in place!" Pulling an impaled knife or rebar out removes the mechanical tamponade, triggering catastrophic uncontrollable exsanguination. Instruct the caller to stabilize the object with bulky dressings.
• Open Sucking Chest Wounds: If air is hissing or bubbling from a chest wound, do not seal it completely with airtight tape (which can convert an open pneumothorax into a fatal tension pneumothorax). Keep the wound covered lightly, or coach application of a vented commercial chest seal.

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Protocol 29: Traffic / Transportation Accidents

Motor vehicle collisions (MVCs) involve complex kinetic energy transfers. Protocol 29 uses Mechanisms of Injury (MOIs) to predict occult, life-threatening internal trauma before field responders arrive:

High-Acuity Crash Mechanisms and Their Codes

Protocol 29's DELTA codes are 29-D-1 Major incident, 29-D-2 High mechanism, 29-D-3 High velocity impact, 29-D-4 Hazmat, 29-D-5 Pinned (trapped) victim, 29-D-6 Arrest, 29-D-7 Unconscious, 29-D-8 Not alert with noisy (abnormal) breathing, and 29-D-9 Not alert with normal breathing. The crash type is carried in the suffix — N ejection, P overturn (rollover), R possible death at scene, M auto versus pedestrian, L motorcycle or bicycle versus auto, Q vehicle off a bridge or height, S sinking vehicle, and F a multi-vehicle pile-up of ten or more — while U, V, X, and Y record unknown or multiple patients with or without an additional response requirement.

1. Complete or Partial Ejection: An occupant ejected from a motor vehicle experiences a 30-fold increase in mortality. The body strikes pavement, guardrails, or obstacles at vehicular speed.
2. Rollover Collisions: Inversions and roof-crush impacts generate unpredictable multidirectional deceleration forces, conferring severe cervical spine fractures, crushed chests, and multiple occupant collisions.
3. Fatality in the Same Vehicle: If another passenger in the vehicle is confirmed deceased, the kinetic energy transfer to the entire passenger cabin was universally lethal. All surviving occupants—even those walking around and claiming to be uninjured—must be triaged as severe high-acuity polytrauma patients.
4. Entrapment / Extrication Required: Patients pinned under collapsed dashboards, crushed doors, or steering columns require specialized heavy rescue hydraulic tools (spreaders, cutters, rams), extending on-scene transit times.
5. Hazardous Cargo / Tankers: Involve chemical placards, fuel leaks, downed high-voltage power lines, or vehicle fires, demanding fire suppression and HAZMAT turnout.

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Protocol 39: Active Assailant (Shooter)

MPDS Protocol 39: Active Assailant (Shooter) — added in MPDS v13.3 with its own Fast Track and critical caller instructions — provides the prehospital dispatch architecture for active shooter and mass violence events. The IAED first introduced the Active Assailant protocol on the police side as PPDS Protocol 136, developed with the National Tactical Officers Association. Be careful with the numbering: MPDS Protocol 34 is Automatic Crash Notification (A.C.N.), the telematics-initiated crash protocol, and has nothing to do with hostile events. It coordinates survival coaching for callers while mobilizing multi-agency tactical emergency medical services:

1. The "Run, Hide, Fight" Survival Framework

When a caller is trapped in an active hostile shooting environment, the EMD delivers scripted life-saving coaching based on the internationally validated Run, Hide, Fight doctrine:

                          RUN, HIDE, FIGHT FRAMEWORK
                                      |
         +----------------------------+---------------------------+
         |                            |                           |
      1. RUN                       2. HIDE                     3. FIGHT
  Accessible escape?           Trapped inside?             Imminent danger?
  Leave belongings             Lock & barricade doors      Improvise weapons
  Keep hands visible           Silence phone & vibrate     Aggressive physical action
  Do not stop for others       Out of sightlines / dark    Total commitment to disrupt

• RUN: If there is a safe, accessible escape path, the caller must evacuate immediately. Tell them: "Leave your personal belongings behind. Keep your hands empty and held up high so police know you are not the shooter. Run away from the sounds of gunfire."
• HIDE: If escape is cut off, the caller must seek shelter in an office, classroom, or lockable room. Tell them: "Lock and barricade the door with heavy furniture. Turn off all lights, close window blinds, and silence your phone completely—turn off the vibrate mode. Stay low to the floor, away from doors and windows, and remain silent."
• FIGHT: As an absolute last resort when the assailant enters the room and death is imminent, tell the caller: "You must fight for your life. Commit to taking the shooter down. Throw objects, use fire extinguishers, work together, and attack with full force."

2. Telecommunicator Safety Shielding

During active assailant incidents, dispatchers must maintain strict operational discipline to avoid betraying victim positions:

• Phone Discipline: When a caller is hiding, instruct them to speak only in whispers. If the shooter is nearby, instruct the caller to keep the line open without speaking. Never place an outbound callback to a dropped phone in a hiding area—the incoming ring or vibration can betray their location to the gunman.
• CAD Tactical Hygiene: Do not broadcast specific hiding locations or room numbers over unencrypted, publicly monitorable radio channels where the assailant or social media monitors can overhear them.

3. Rescue Task Force (RTF) Integration

Historically, mass casualty shooting response was paralyzed because medical crews were held in staging areas for hours while SWAT teams searched every room, during which victims with survivable extremity bleeding bled to death. Modern doctrine deploys the Rescue Task Force (RTF):

• Warm Zone Operations: The RTF consists of EMTs/Paramedics outfitted in ballistic armor (helmets and tactical vests) operating in the Warm Zone under direct armed protection from a Law Enforcement Force Protection team.
• Mission Focus: The RTF does not perform comprehensive clinical exams. They deliver immediate point-of-wounding interventions—applying tourniquets to spurting limbs, packing junctional wounds, sealing open chest cavities, and placing recovery positions—before rapidly extracting casualties to external Casualty Collection Points (CCPs) for ambulance transport.