Understanding and expanding the scope of preparedness for mass violence incidents

By Diane Alexander, Tara Hughes, and Corina Solé Brito

Jul 15, 2022

Editor’s Note: The following content deals with the sensitive topic of mass violence. Some listeners may find it distressing.

We invite you to listen to the second episode in a new series discussing large-scale violence and domestic terror—a sensitive topic that impacts us all. In this conversation, Corina Solé Brito, an ICF director of Public Health Preparedness and ICF’s Deputy Director of the U.S. Department of Health and Human Services ASPR TRACIE, joins victims support services experts Diane Alexander, with OVC TTAC, and Tara Hughes, who is also the director of Improving Community Preparedness to Assist Victims of Mass Violence and Domestic Terrorism Training and Technical Assistance Project (ICP TTA). Together, they explain the critical need for pre-event collaboration and communication between jurisdictional incident response team members, the various and significant effects of mass violence incidents (MVI) can have on survivors, responders, and communities as a whole, and the importance of supporting responder resilience before, during, and after an incident.

This podcast series was recorded in April 2022. ICF has been providing immediate assistance to communities after an MVI for over 30 years. In this podcast, we share guidance and advice on how communities can create a plan to respond to MVIs and identify and develop strategies to address the short- and long-term needs of the people they serve.

Some of the topics discussed in this episode include:

The importance of establishing intercommunication between first responders and service providers in an incident response
Understanding the role of state victim assistance and compensation services
Expanding the scope of preparedness to all types of health care providers—not just hospitals
Identifying the incident response team
Recognizing the emotionality of an event of mass violence
Providing short- and long-term care for first responders
Information distribution and the importance of Public Information Officers (PIO)
Separating the location of the incident location from victim’s services
Creating plans that take vulnerable populations into consideration
Establishing personal and professional contingency plans
Taking the next steps toward mass violence incident preparedness

Transcript:

Diane: Good day, and welcome to our second podcast on mass violence planning. My name is Diane Alexander, and I'm a senior manager in victim services at ICF. And I currently focus my work on managing support to communities that have experienced a mass violence incident and helping those communities plan for how they will respond to a mass violence incident.

I'm joined again by Tara Hughes. Tara is a subject matter expert in mass violence response, working directly with victims and families to ensure comprehensive care. She's the project director of the Improving Community Preparedness to Assist Victims of Mass Violence and Domestic Terrorism Training and Technical Assistance Project, and oversees work with communities to plan for mass violence response. Tara and I are joined by Corina Solé Brito.

Corina wears two hats at ICF. She serves as a director of Public Health Preparedness, and she's the deputy director at ASPR TRACIE. She has a master's in criminology and has been working with first responders, emergency managers, and health care workers for 30 years. In our first podcast, we talked about the definition of mass violence, how planning for a mass violence incident is different than other types of emergency planning, the importance of good comprehensive planning that must happen before an incident, and we touched on the challenges of not planning.

We also talked about how when communities don't have a plan in place, services to victims are delayed or even denied. Today, we'll talk about what happens when you don't plan for a mass violence incident and what makes a good plan. Tara, why don't you start us off?

Getting all service providers in the room

Tara: Thanks, Diane. Sure. We ended last podcast talking very briefly about the Boston Marathon bombing response, and one of the things that we found in that response was that tactically, operationally, they had lots and lots of plans in Boston and the surrounding areas. They have plans for every marathon that happens. They have plans for every football game that happens, every New Year's Eve concert, and set of fireworks that happens.

And all of those plans talked about tactical operations. What they didn't talk about was victim services. And so what happened in those moments when the victim services people arrived was a lot of resistance from people within the organization as it was functioning tactically to letting victim services do what we needed to do, and it really took quite some time for the people who knew what needed to happen from a victim services perspective to actually get into the right rooms to be talking to the right people. So specifically what happened was I was with the Red Cross and that response and I had the Department of Health who was in charge from a city perspective—a Boston city perspective—calling me and asking me for lists of names of providers who might be able to set up counseling with families.

And that was what they envisioned as a good plan and as what was needed. And what we know is needed is not that at all. That, actually, counseling services don't generally kick in the typical sense of counseling for weeks and weeks and weeks, and that that is appropriate. It takes people a long time to get to the point where they are able to navigate actual counseling sessions.

But what's needed is victim services in that moment. How do we support people as they get information? Information about their loved ones, whether their loved ones are deceased or living, whether they're in the hospital, whether they don't know where they are—how do they get that information?

How do we support them while they get that information? What other services are needed? We had people in the Boston Marathon running the marathon who were from other countries and from across our country, and what they need in that moment is not necessarily typical traditional counseling. But what they need is the ability, if they have the physical ability, to get on an airplane and to fly home.

And some of those people didn't have access to their IDs or those kinds of things. So generally, what happened and what got this moving in the right direction really was the fact that most of the people who were coming in from a victim services perspective—the FBI has victim specialists, the local MOVA (Massachusetts Office for Victim Assistance) has victim advocates. The attorney general's office is where victim compensation sits in Massachusetts.

So they had advocates who needed to get in. Most of those people, other than the specific Massachusetts people, had worked together very recently at Sandy Hook Elementary School and the response that happened after that shooting. So the FBI, the Red Cross, the uniformed public health folks—there were some others from a national perspective who had just done all of that together. And as we all landed in Boston, we started talking to each other.

And bringing that information to the table to say, here's what we need. Here's what we need to do, and we knew what we needed to do. Many of us not only had just done Sandy Hook together but had done this multiple times prior to that. So we were able to get into contact with the Massachusetts Office for Victim Assistance, the attorney general's folks, and bring a meeting together. That meeting morphed into really a day-long journey to try to get the city to start to work with the victims the way that they needed to be worked with.

Bringing them to one place where their needs would get met. Giving them support in the hospitals if they were there. Helping them with lodging or transportation or those kinds of things. So what we found was having a group of people who knew each other, who had done this work together, who had talked through some of the issues at Sandy Hook, were able to then bring that to the attention of the city and be able to talk with them, get in a room with them and really talk with them about what was needed and how we move forward.

So that meeting where we all got in the same room happened on Wednesday at 11 a.m. The bombings happened on Monday afternoon around 2:15 p.m. or somewhere in that range. So it took a long time to get there. We eventually got there. We eventually had really good services for the people who were identified as victims, but there was a two-day gap where there were a lot of things that fell through the boards, and we don't know what we're still missing today.

So thinking about planning—yes, tactically, that was there. And there were good plans in place and lots of relationships and people with different organizations working with each other. What wasn't there was the fact that they needed to realize that the victim services pieces had to be activated as well. Thinking about that moving forward and planning now there is a much more robust victim services component to the plans. Even for the traditional everyday things. The Boston Marathon just happened last week and those plans now have victim care components in the plans.

So luckily, Boston has learned from those lessons and has moved their plan much forward, but we're really looking at ways to make sure that relationships happen and that people know what the very specific things that need to be activated during a criminal event are activated — and when there are living people who were impacted who need services as opposed to just fatality management. Back to you, Diane.

Understanding the role of state victim assistance and compensation services

Diane: Tara, can I ask you a follow up question? You mentioned both victim assistance and compensation. Can you give the listeners just a little bit of a shorthand of what those mean and why they're important in the planning process?

Tara: Absolutely. So Victoria [Shelton] did this in the last one, but I'll give a very brief follow up to what she did for those just listening to this one. Victim assistance is really an overarching program that exists in states to assist victims of crime—any crime—to get the services that are needed for them. And those services can be immediate services, so they can be mental health support. They can be long-term mental health counseling.

They can be physical, medical support—all of those kinds of things. But that victim assistance, those advocates will walk next to people throughout their entire journey of this crime and their response to the crime and get their needs met, and victim advocates who work through victim assistance at the state level will help navigate them to the appropriate services. Victim compensation is the financial compensation that covers a variety of different things depending on the state.

It covers a variety of different aspects of what a crime victim has to deal with—medical bills, mental health bills, rehab, physical rehab—any of those kinds of things can be covered by victim compensation. It is very state based, and so each state has a different set of things that are covered by that. But, in general, that's what victim assistance and victim compensation are. They both kick in when there is a crime.

Diane: Thanks, Tara. And the one thing I would add about compensation is we see in a lot of communities GoFundMe pages set up a fund set up and the donations, and it's really critical to know that what crime victim compensation will cover so that if you have people wanting to donate to say cover funeral expenses, there's already a mechanism available in your community and your state to have funerals covered by state crime victim compensation. So put those donations to other types of needs that a victim might have that wouldn't be covered by crime victim compensation.

So it's just being smart with how you're looking at funding the needs of the victims—the direct needs.

Tara: Absolutely I would say that. And planning that ahead of time knowing that there are people who know what gets covered by official funds and creating and developing communication that already takes that into account. If we know that victim compensation is going to cover funeral expenses, we know we can direct people to use different wording in their funds or those kinds of things, so preplanning is where that can all be set up ahead of time.

Expanding preparedness to all types of health care providers—not just hospitals

Diane: Exactly. Corina, do you want to jump in and share your perspectives?

Corina: Sure, thank you. I was going to take it back a little bit earlier in the earlier phase of the response and say from an emergency response and hospital incident management perspective, even though we have incorporated a bunch of lessons that we've learned since the Boston Marathon incident, we still encountered some similar challenges after the Las Vegas shooting and I wanted to highlight some of that, too.

Victims self-reported to eight different hospitals, and many of them were dropped off by strangers and most of them had not gone through any type of traditional on-scene triage. In fact in one hospital only, patients arrived via 24 EMS transports but 188 private vehicle transports. Some came without identification, and this really slows down the treatment and notification process. So it's really important for hospitals to ensure an adequate supply of things like paper triage tags or paper charts just to keep the process moving after a mass casualty incident.

Tara: And the other thing that I would say with hospitals is really looking at the fact that hospitals are part of the picture and coroners and medical examiners are part of the picture, and victims who are not injured enough to go to the hospital still need to be accounted for. And so really looking at how do we pull all of that information together. Pulling all of that information together allows a community to get a comprehensive list of victims and helps people to be reconnected with their loved ones.

And sometimes that is a family finding out that there was a death, but sometimes it is a family finding out that someone's in a hospital, doesn't have their ID, and their name isn't on a registry in that hospital right now because maybe they have a concussion, and they don’t remember their name in that moment. In Las Vegas, there were—my understanding is that there were nine people who were treated and released and they never knew their names or they never recorded their names. So there’s all sorts of different things that happen that preplanning, pulling all of those people together and talking beforehand to facilitate comprehensive lists of people that they are treating and identifying all of those people coming in very non-traditional ways into hospital settings.

The other thing that we’ve seen—and Corina, I think you can talk more about this, but people went to things like urgent care because that was the closest thing they came to and they didn’t know where the hospital was. They were maybe from out of town but they found an urgent care so they knocked on that door, and they were treated there first and maybe transferred to a hospital and maybe just treated and released.

Corina: Absolutely, and the more things like this happen, the more important it is to include all types of health care providers into emergency management planning. But particularly hospitals, because the hospital family information centers are obviously in the hospital, and keeping these folks included in every type of planning and exercise that you hold can ensure a smoother transition to a community Family Assistance Center.

Tara: Absolutely, and I think that one of the things that we've talked about in a number of ways in both of these podcasts is scope and scale and that traditional protocols, standard operating procedures work for a while but often don't work when the scope and the scale gets to be so big that you have 120 non-traditional vehicles bringing people into a hospital setting that we don't do that in a normal every day in an emergency room—or if you do, it's one person who's bringing one person in a vehicle.

And so thinking about the challenges of scope and scale and that that is why additional planning is needed. It's not for the smaller things, where standard operating procedures will kick in and work really well. Hospitals have those. Medical examiners have those. Coroners have those. It's when it gets to be really, really large. And when each of those has a piece.

So if we go back to Las Vegas, the medical examiner's piece of that was the—I'm sorry, he's a coroner. The coroner's piece of that was the management of the remains and talking with families and identifying those remains and giving them their death certificates and all of that kind of stuff, and that all fit within his lane, and he did that according to his standard operating procedures. What wasn't taken into account by that process was the fact that there were lots of people who ran away from that site who were not injured, didn't end up in the hospital, did not end up dead, but were very much impacted by that mass violence event and that a response needs to take into account all of those components and not just the ones that any given entity does with their standard operating procedures.

Identifying the incident response team

Diane: Right. Great information. Before we move on to elements of good planning, any other final thoughts from either of you about the challenges with planning and what you've seen when a plan isn't in place?

Tara: So I think one other thing that I would say is that one of the—again, it goes back to what I was just saying. It's a multi-pronged need to account for people that includes those who are involved, those who are injured, those who are missing, and those who are deceased. And that there needs to be at the early stages of any given response, there needs to be a working definition of who will be considered a victim of the incident, and that's going to need to happen across the board for any incident that's out there, and what happens with poor or no planning is that those conversations happen between people who really don't talk to each other all that often about something that is this large.

So generally, it's the lead law enforcement agency, the eventual prosecutor if there's a live perpetrator, and, hopefully, the victim services people all coming together to really look at who is impacted by this and how are we going to define that, because that will immediately dictate who gets access to services. So when you don't have a good process or even have the people know each other ahead of time who are going to need to come together and make that decision, that becomes an even more challenging decision than it would have been otherwise.

Corina: Yes, I completely agree. And I would say that defining who will be the actual incident commander is super important, too, even before you get to the phase where you're providing victim services. It’s so important to get to know your entire incident command team from the hospital perspective and the community law enforcement and first responder perspective before an incident takes place.

Diane: Great. Great information. Thank you both of you. So let's turn our attention to the elements of good planning. Would the two of you from your experience like to talk about what are the components that you have seen in good planning?

Tara: So I'm going to jump on what Corina just said in terms of knowing whose job it is to do what and having those conversations ahead of time. What we have seen is a plan that is socialized among the people who will be carrying out the plan is really important, and that socialization happens by the planning process. The planning process is not a one-size-fits-all for every community, and that's why it can be challenging.

So a good plan, as it is being developed, allows for people to sit down in the same room and talk to each other and maybe talk about some negative things that happened in the past related to other large incidents. Maybe some really good things that have happened in the past and get to the point where they jointly decide, here's what's going to happen moving forward. So those discussions and the people understanding who's going to do what and how it's all going to fit together is actually, I think, one of the biggest benefits of planning, and the mark of a good plan is that it is community-specific. So Corina, how about you?

Corina: I love that you said that it's community-specific because we totally agree. From our perspective at ASPR TRACIE, you can have a plan, you can practice the plan, but until you bring in the players from your local hospitals and your local emergency management services to get to know each other and to practice a plan together, it's really just a piece of paper or a binder. Something else that we've heard a lot of in the past is that it's important, it's great to plan, it's great to exercise, but you really need to take that to the next level and plan for something you think would never happen, because that might happen.

And then something else you never thought would ever happen will happen afterwards. I know it sounds dramatic, but add injects that you really could never imagine, because at this point, these are things that may actually be your reality.

Recognizing the emotionality of a mass violence event

Tara: No, I love that. I love the idea of planning for something that you don't think will ever happen. One of the things that we have found as we work with communities in the planning process is that when we help them to plan for those outlier things that maybe have happened in other communities but they seem really dramatic or they seem really out of the norm—when we have them really think about those, then when they talk about the things that more generally do happen, they use that information that they've learned from that dramatic thing and they're able to generalize that to the bigger plan or the bigger needs that may happen more commonly, so I love that.

The other thing that I think is really important, and Corina, I'd love to hear your thoughts on this. But the idea that of the emotionality of a mass violence event really is in many ways outside the norm that we deal with. Yes, any event, any incident that happens or illness that happens impacts a family or impacts an individual and there's a lot of emotionality around that.

But what we see in these mass violence events is that emotionality not only gets bigger and expanded to the community that people are living in, but often, to the community of the world depending on the who is impacted. If there's a shooting in a synagogue, that impacts the Jewish community worldwide, really. Sandy Hook Elementary School, there were 20 children ages 6 and 7 who died, and that impacted the community of the world—a large community of the world was really impacted by that.

So emotionally, you can't really plan for specific emotions, but you can plan for the fact that there will be a lot of emotion and that some of that emotion may be devoted to, what was the intention of this? And what's the why behind it—why did this happen? What made this person-—after the Gilroy Garlic shooting a few summers ago, I was sitting in a meeting, and it was very important to some of the victim families who are sitting in the meeting to find out what made the person who did this do this.

And that was not something that we could necessarily answer, but that intentionality—there had to be an intent or there had to be something that created this, the environment that created this person. That increased the emotionality of everything, and it was harder for people even to hear about services and process the fact that the services were going to be available to them because they had this emotionality that kept getting in the way. So I would love to hear about how you think that impacts hospitals, both from the provider perspective and the patient and family perspective.

Corina: I mean, it's so hard to reconcile the type of things that other humans can do to each other, right? Sometimes, it's impossible. So it makes sense that people want to know the why, but sometimes you just never will. I think it's really important to incorporate all of this into your planning and to know that you're going to have upwards of 100 family members—or their loved ones are coming to your hospital, looking for their people, and needing support. And maybe they don't have their IDs or they don't have food or water because they came from the same event.

And some of these may be children or other loved ones of your health care providers because, again, like you said, these plans are community-specific. Well, these events are community-specific, as well. So a lot of your responders may actually have friends, family members, et cetera, who work in hospitals and vice versa. So it's really important to consider these things when you're planning for mass casualty incidents.

It's no different than planning for a wildfire because these are things that affect your communities. But like you said, they affect the world as well. So thank you, social media and traditional media who jump on it and just share all these images repeatedly over and over again. It's so important to have victim services staff, patient health care workers, everyone supported by behavioral health, mental health professionals that can come to the hospital that are usually in the hospital who work in the hospital and provide some sort of on-site crisis debriefing and support.

What you provide to humans is pretty much the same no matter their role in a response. There are survivors, their loved ones, their health care provider. It's just specific —it's just supportive feeling, supportive food, supportive care. It's basic needs that can be planned ahead and carried out in a hospital-based Family Assistance Center.

Providing short- and long-term care for first responders

Tara: Absolutely, and one of the things I would add to that is that we know that hospitals across the board, after events like this, lose staff. That people who sit in an emergency room for hours and hours and hours and see the physical and emotional ramifications of this, we see them leave their jobs. We have a colleague who went to Las Vegas several weeks, several months or years, I'm not sure—Diane can fill that in—went to Las Vegas and was having her nails done and found out that it was someone who had been an emergency room provider.

She had been a nurse, and she walked away from nursing after that because of the emotional toll.

Corina: Yeah, I would piggyback on that and say it's helpful-- while it's very helpful to provide the debriefing in the moment—in the heat of the moment—during the response and maybe some time afterwards, it's critically important to maintain that throughout the long-term as well for health care providers in particular as well as survivors, just because, as we all know, first responders are trained to respond and not really think about what they're doing from an emotional standpoint. So it all comes out later. At this point in time, we can't afford to lose any more health care workers to stress, so it's important to have some really good solid programs set in stone in your hospital and other health care facility.

Tara: And that makes me think of another component that hospitals have to think about. First responders across the board think about it, but hospitals have to think about not just the incident that they're hearing about on a radio and people are being sent their way, but they then have to think about a secondary explosion or a secondary incident. So do you want to talk a little bit about that in terms of how challenging that is both from a response perspective but what you were just talking about in terms of the people who have to work under those conditions?

Corina: Yeah, thank you for bringing that up. It's so hard to say that hospitals are targets, right? You never really want to think of them that way, but it's really important for hospitals to plan for secondary incidents and to plan to be attacked in a similar fashion. And it's also really important to understand that the response in the first responders are going to be overwhelmed.

And I think it's easy for me to say, but if you look at the numbers. For example, in Las Vegas, the incident scene expanded from 17 and 1/2 acres to 4 square miles, give or take, because as people ran and called 9-1-1, first responders had to figure out whether there was one shooter or multiple shooters and where the locations were, because the calls were coming in from all over the place as people evacuated the scene. So that’s something that’s really important, and you will have some scope creep affecting your hospital, your emergency department as well.

There are also other ways that hospitals can plan to harden their targets by working with their emergency room security and things like that. But again, your job is to keep your doors open and serve victims and patients and their loved ones. So it’s really a thin line there.

Tara: Absolutely. Diane, back to you.

Diane: I was just going to say, Corina and Tara, going back to the anecdote that you shared, Tara, about one of our colleagues going and having her nails done by somebody who was an emergency room nurse. She was an emergency room nurse in I think the trauma one hospital there—the highest level of trauma, and they had trained.

They had done a lot of training. They had a lot of plans and everything, but I think what is important from her experience is even with all that training and all that planning, you do need to think about, as Corina mentioned, you’re doing the debriefings and everything in the immediate aftermath, but really being able to look at the long-term services you offer to your first responders, your employers, and being able to really set something up that keeps them in their profession—their chosen profession, whether that’s hospitals or first responders or anybody else in those types of professions. We want them in all their experience to stay in their roles.

Tara: Absolutely, and I think that we know from lots of these experiences that first responders also leave in droves sometimes. You look at 9/11 and the FDNY had, almost within five years, I believe 50% or some number around there of their firefighters had either switched departments and gone somewhere else or dropped out of being a firefighter in general. And so as Diane said, not only are you losing those people, but you’re losing that experience and you’re having to start over from the beginning and train.

So thinking about from a planning perspective, what can you do to really have a robust response for your responders—whether that’s hospital first responders, even the people who work in the sites that get stood up just for mass violence, the family and friends notification center and the Family Assistance Center. Those are really tough jobs to have. And to have the awareness that you need something more robust than the norm is really important, and I think we go back to those relationships and the conversations that you have ahead of time that your Fire Battalion Chiefs can say, we’re good on a normal everyday basis, but we may need to reach out to X group of mental health providers or spiritual care providers to assist their chaplains or those kinds of things.

So giving communities the ability ahead of time to think about how do we really truly care for the people who stepped up and cared for the people impacted by this is huge. It’s huge. I always consider that one of the gifts of this work is that we get to allow people to see that they may need something more and give them the space to create it, whether they like our gift or not is always another question. But, in general, it’s an opportunity that really allows them to figure out how do we care for our own in the long-run and do it effectively.

Diane: Yeah.

Corina: I couldn’t agree more. I think it’s so important to continue working to remove the stigma associated with admitting that you need some help to get through a difficult situation. I mean I think in the first responder world, we’ve made some progress but we have a ways to go obviously, but I do believe that there are things you can do to make yourself more resilient and there are plenty of tools out there for first responders, health care workers, and victim services providers that we just need to do a better job socializing.

Diane: And I’ll put a plug in for when you’re looking at setting up those services for the first responders is to keep in mind their families and making sure that their family members have access to services and support as well.

Corina: I wish I could high-five you through this microphone here. I completely agree.

Tara: I was thinking the same thing. Absolutely.

Information distribution and the importance of Public Information Officers (PIO)

Diane: So let’s switch gears just a little bit and start looking at some of the more unique challenges in planning and response. And Tara, I think you want to kick us off with using your public information officers?

Tara: Sure, so public information officers are a gold mine of information and protocols and abilities, and we really, really need to be using those. One of the things that we have unfortunately seen over and over and over again after these events is that there are liability issues that come up. And that with those liability issues, many organizations get sued, and it is one of those unique challenges that a lawsuit can happen any time, but with a mass violence incident, often, they are very quick and they are very extensive, and sometimes, they’re numerous as well.

So thinking about who can get who can get sued and how do we protect against setting things up so that there’s more of that opportunity. We have seen—and Diane can help me with this—but we have seen schools, universities, police departments, fire departments, victim service agencies, nonprofits, all of them get sued after effect at one of these incidents. So that really points in many ways to the fact that if you are in one of those organizations, that having your PIO who is trained to stand in front of people, who is trained to give or not give information and is also planning what they are or are not going to say before they go out there—that the use of a public information officer in a coordinated way with other organizations and having single messaging, having that include some ideas of what people might be experiencing and ways to take care of yourself, and all of that kind of stuff that that really can—not protect against lawsuits, but it can shield some organizations from the bigger things that we’ve seen happen.

What we know is that the more that is said by government officials and leaders in those moments, every word of that gets reviewed thousands and thousands of times by people and can become a liability. So definitely think about using your public information officers.

Diane: And no doubt that it’s a challenge, because a leader, an elected official, the chief of police, a sheriff, they will probably naturally feel like, “OK, I’ve got to be out there in front delivering a message to the public, the media, the victims and everything,” and what is I think challenging with that is that—no offense to any of them—but they’re not necessarily disciplined public information officers in the way that PIOs are. So you want them to step aside, maybe introduce the PIO. So if they do need to have a visible presence at any sort of briefing, but then step aside and let a PIO provide that briefing to the media and the community, especially.

One of the things to touch on, Tara, I think is the idea of institutional victims. We know in the work that we do, a lot of entities, businesses, schools—things like that—want to be able to do the right thing when something has happened, and in their mind that may be, well, we want to be able to set up the services that are going to be needed for the victims and survivors.

And what we know is that they’re essentially what we call the institutional victim, and so they are not usually the best position to be providing services. There may be those lawsuits that you’ve mentioned, but there may also be feelings about the organization where the incident happened, and they also have their own trauma to tend to as the institution where the incident occurred. So we always try and look for another community entity that’s not connected directly to the incident to be able to set up services.

Separating the location of the incident location from victims’ services

Tara: I think that another component of that is the idea that the entity may be a business and the shooting or the incident may have happened on the business property. It may be an institution, a police department or something like that responded, and there are quite a mix of emotions that generally tend to happen around the location of the incident and the response to that incident. So you have a school, where families are known in schools. And school administrations pride themselves on taking care of their people, taking care of their students and their families.

And what we find is that they may very desperately want to do that, and families may be very angry because of things that happened during that response or policies that the school has. So there may be this anger that families and students can’t get over. And what we find is rather than figuring out how to manage that emotion and going to get services if they happen to be in the school or if the school is facilitating them, victims tend to not take advantage of services. They will go elsewhere to try to find their own services, and we know that that’s really, really challenging.

And the goal when we set up these responses is that people don’t have to do that. So one of the ways that we really encourage people is to make sure that where the incident happened is not where we’re asking people to go for services, because that is something that is incredibly challenging. And, again, people will forego services and just not get them rather than go to that place where they feel that anger.

Creating plans that take vulnerable populations into account

Diane: Great point. So let’s continue moving forward. Can we talk a little bit about how a mass violence event will impact the vulnerable people in a community?

Tara: Sure. It will impact the most vulnerable. It always will. And in a variety of different ways and capacities. But you’re really looking at people maybe who are differently abled. Maybe have mobility issues or hearing issues, sight issues, those kinds of things. And any of these incidents of mass violence are going to impact people who fit in those categories more, because it’s, in general, more challenging to get services across the board.

And so now, very quickly, you’re setting up community support systems that need to not only have interpreters there and have the ability to work with people who now have different family configurations and different cultures, people eating different things, all of those things need to be thought about very quickly and very compassionately and empathetically. And you need to think about how are we managing the vulnerability of the people who are here. We, in many of the instances that we’ve had, have had undocumented folks who were impacted.

We have had folks whose families are in foreign countries and they don’t have support systems here. So understanding that mass violence is going to impact people and going to require a whole set of interventions that are much more broad than the normal things that happen in a community. And that we are going to need to, in the response, figure out how to manage all of that. And sometimes, that means that if you have a pocket of undocumented folks, they are very unlikely to come into a service center like a Family Assistance Center.

So it becomes important to figure out how to identify these pockets of vulnerable people who are not accessing services and figure out how do we package these services in a way that one, we can move them out there, but two, they’re accepted by all of these populations. We may need to get consulates involved. We may need to get, as I said, interpreters involved. We may need to make sure that there are all sorts of functional and access needs that we’re meeting when we’re setting up the facilities that we have for things that existed prior to this but also are new access and functional needs.

When we were in Orlando for the Pulse response—when I walked in and they had set up the Family Assistance Center, they had tables, many tables that were put there expecting lots of families to come in. And there were lots of chairs, and there was no space between the tables for a wheelchair. So I said, we need to get rid of probably six to eight of these tables and make sure that wheelchairs can effectively move in and among these tables. And I got a little pushback at the beginning. But we want enough tables for all of the families.

And I said, yes, and what you’re going to have right now is have a lot of families who have people who are just released from the hospital in wheelchairs, maybe because they have leg injuries, back injuries, those kinds of things, but may just not have the strength to stand up and they’re not going to be able to come in. So they’re going to be at the door, and they’re not going to be able to navigate this. So even thinking at that level when you think about planning, having a plan to think about how do we manage that?

How do we make sure that people who are newly dealing with functional and access needs can do it with the least amount of challenge as possible?

Diane: And I think one of the important points to take it back to the need for planning is that when a group is sitting down to plan their mass violence response, they need to be looking at, “OK, what’s the makeup of our community?” Because in many communities, those underserved populations may not be coming to the forefront of their mind as they’re planning, and so they really need to have somebody at the table saying, “But wait, what about this community or this population?” so that you’re not scrambling at the last minute when an incident affects somebody from one of those underserved communities.

Tara: Excellent point. Absolutely. And those community surveys are done typically by a number of different organizations in a community. Emergency management do it all the time, as well as hospital systems, health care systems. Schools even do it. So the information is out there—you just need to have the right people at the table and you need to have the conversation ahead of time.

Establishing personal and professional contingency plans

Diane: Unless we have any other thoughts on this particular point, I was going to move us to personal preparedness. So Tara, Corina, are we ready to move on or do you have any last thoughts on this past section? OK, so one of the things we’ve learned over time is that people react to large stressors and recover better if they have a personal preparedness plan. I’d like to have Tara and Corina come back in here and talk a little bit about how do you personally prepare for this type of an incident and your response to it?

Tara: So I think on a personal level, I’ll start there and then I think we’ll both talk about the personal-professional level. But on a personal level, being able to respond as a responder to any of these or really even manage what’s happening in your community is easier if you have some basic personal preparedness stuff in place. And there are two major categories that I always think of when I think about this. One is communications.

So thinking about if the norm of my communications system, like how do I talk to my kids after school or when they are ready to come home from a soccer practice or any of those kinds of things? If that is broken down, what can we rely on? And what can we put into place to make that happen?

One of the things we know is that after an incident happens in a community that there are a lot of official channels that are using cell towers and radios and all of those kinds of things. And sometimes it’s harder to get personal use of cell phone—calls won’t go through because the systems are busy. The other thing we know is, especially if it was a bombing and there’s that threat of a secondary device or a secondary incident, they’re often turning off the cell towers periodically—actually turning them off for the most part and then turning them on periodically, because what we know is that cell phones are used to detonate bombs.

And so all of that means that it’s going to be very hard for me to get a message or a phone call to my children or to my elderly parents or to even a significant other, my spouse or whoever it is. And so creating different ways to communicate and from a personal perspective, my sister was lived just north of New York City during 9/11, and her cell service between herself and her three children and her husband was completely cut off for about five days. And so all of that communication was coming through me.

I lived on the other side of New York state, so they were all able to call me over there or text me over there, but not able to text each other when they were a few streets away. So there was a lot of back and forth. We did not know that prior to 9/11 that that was going to happen. We were very quickly able to implement it once that happened so that everybody knew that everybody was safe and where people were and all of that kind of stuff.

That’s one example of how to do it, but coming up with a communication plan. The other thing to plan is child contingency plans or elderly contingency plans. If I cannot pick up my child at school because a bomb went off in between my house and the school and I can’t get there, what’s going to happen to my children? Who else can go pick up my children?

What are the plans? How can we set this up? And it may not be that I can right now identify who—I know who would be on the same side of the bomb as my children, but what I can do is set up things like code words that if I have young children and someone comes to pick them up at school who is not me and is not their normal person but has a specific code, says a specific thing to my children, they know that I sent them to pick them up and that something happened and that I can’t be there. So coming up with contingency plans like that for children, for elderly family members who may be in elderly care or nursing homes and you’re just trying to get information about them, those kinds of things.

So as a person, those are the kinds of things that I would do. Corina, do you want to talk about either that or that end as a professional responder what we can put into place?

Corina: Sure. I think I would echo what you just said about communication being super important and having alternatives, because just recently, my son went through Hurricane Ida and completely lost cell communication for about five days, as well. So it was really important to have a backup plan. I think on-scene, communication is equally important, but it’s so important to have someone like a buddy to communicate with. If you identify somebody on-scene that you’re working with who can recognize signs that you may not realize you’re giving off and vice versa, you can help each other spot when the other is maybe having a bit of a rough time.

We like to talk about resilience and building resilience before you deploy because you know you’re going to be in an austere environment. You know you’re going to have challenges associated with of a host of factors. With COVID, it would be PPE. In some cases, it’s language barriers. In some cases, it’s just hearing traumatic experiences or seeing trauma repeatedly day in, day out.

So I think for some people, it can just be really helpful to even just list how you feel like you might react or how you react to these sorts of triggers and then come up with a list of things you can do when you feel yourself reacting to those triggers. What’s helped you in the past? What do you like to do to help you relax?

When you have control, how do you feel? When you feel like you don’t have control, how do you feel? What can you avoid when you’re on these assignments, and then your typical stress management tips that we hear over and over again. It’s so important for us to actually pay attention and act on them.

Don’t work more than 12 hours at a time. Limit your exposure to the news. It is OK to say no when you’re not comfortable or when you just are exhausted and need a break, and know what kind of food is healthy and take healthy snacks with you and remember to drink. Drink water. Not drink. Drink water.

Hydrate. Stay hydrated, because you can’t pour from an empty cup. That’s one of my all-time favorite sayings. Some of us refer to this as like a behavioral health PPE or behavioral health self-care plans, but whatever you call it, I think it’s so important to have it in place before you’re deployed before you respond.

Tara: And I would piggyback on there to say that some of the things you talked about are things that organizations can put into place if they’re thinking about things ahead of time. Things like the 12-hour shifts, things like making sure that you are leaving when you’re supposed to be leaving and doing that from a leadership position all the way down. What we know is if leaders say you can only work 12 hours and then work for 72 hours, that what people know and expect of themselves is that they’re going to also work 72 hours, and that that’s fine, well because the police chief did it or whoever did it.

So I think also the planning piece gives organizations the opportunity to put some of that stuff into a written plan. That there will be no longer than 12-hour shifts. That there will be a meeting, like a briefing. Of the people coming in so that the people who are leaving can give information, and all of those things you were talking about that are stress-inoculation related in terms of let’s think about what you might expect out there. Those can be institutionalized by an organization.

Let’s have these conversations in these meetings as people are stepping into these really challenging situations so that we as an organization are setting people up as well as possible to be effective and to be good at what they do and be what we need them as an organization to be.

Corina: Once again, virtual high-five, because it starts at the top. And if the top is modeling healthy behavior, so will all the other levels. Absolutely.

Taking the next steps toward mass violence incident preparedness

Diane: Great information. Thank you both so much. So let’s keep moving forward. So where do we go from here and what are the next steps? What you’ll find on this page where you found the podcast is a list of resources. And I just want to touch on a program that I’m involved in and then I’ll ask Tara and Corina to do the same.

So you’ll see a link for the Office for Victims of Crime Training and Technical Assistance Center’s Mass Violence web page. And this is where you’ll find all sorts of information on planning. How to request technical assistance for your planning efforts. It’s free, I’ll just say that.

Our services are free. We’ll have our library of webinars on the web page and also resources for planning, responding, and recovering from a mass violence incident. Tara and Corina, do you want to talk about your resources?

Tara: Sure. I will go next. So my program is we refer to it as ICP TTA, and it’s really the full name is Improving Community Preparedness to Assist Victims of Mass Violence and Domestic Terrorism, and it’s a training and technical assistance program. So I am also funded by the Office for Victims of Crime, like Diane. And so our services are free, and we focus solely on planning for mass violence and domestic terrorism and bringing together the victim service piece and the emergency management first responder piece, the operations with the victim care, and really helping to knit those together into a very cohesive plan.

A couple of our really—I’m really excited about these resources. One, we have an exercise guide that will help you take an exercise that you already have planned in your community. An active shooter exercise, a bombing exercise, any of those kinds of things and tack on victim care components. All the stuff that we have been talking about, the family and friends reception and notification center, the Family Assistance Center, the long-term resiliency center.

So really looking at tacking that on with injects in a scenario that will take you out there. Connecting core capabilities that emergency managers need to exercise. All of that is done in this guide.

The other thing that we have coming out is a template for an annex of mass violence response. So it’s going to be available on the website, and you can walk yourself through a process of having the conversations you need and identifying all of the components that you need and then putting them into a plan. You can also contact us and we have consultants who will work with you in your community to go through that process to get you a plan. We can actually even write the plan.

The other thing I will say before I pass it to Corina is that OVC TTAC, Diane’s program, and my program, we work very closely together. And one of the things that you will find is we both do planning work, but we will often talk to each other about which program is the best fit when someone calls in. And so it may sound like we do things that are opposed to each other, but we’re actually very cooperative in the process. So call either one of us, and you’ll get both of us, basically. So Corina?

Corina: Thanks. I represent ASPR TRACIE, and that is brought to you by the United States Department of Health and Human Services. ASPR is actually an acronym for the Office of the Assistant Secretary for Preparedness and Response, and TRACIE is an acronym for Technical Resources, Assistance Center, and Information Exchange, so it's T-R-A-C-I-E. We were developed to meet information and technical assistance needs of a variety of stakeholders, including health care coalitions, health care entities, providers, emergency managers, basically anyone who works in disaster medicine, health care system preparedness, and public health emergency preparedness.

We run the gamut. I like to say we cover from A to Z access and functional needs to Zika. We've got a bunch of topic collections that are basically annotated bibliographies, and we do have a mass violence resources page. On that, you can find plans, exercises, tools, templates, and we also have a set of no notice incident tip sheets that are a collection of lessons learned from a variety of mass casualty incidents but really focused mostly on the Las Vegas incident.

And we also have a disaster behavioral health resource page that includes similar resources but also some modules for organizational and health care worker resilience. Thanks.

Diane: Thanks, Corina. And my thanks to you and Tara for sharing your insights and experience with everyone today. Thank you for listening to the podcast. To the folks out there. I encourage you to check out the resources on this page and let us know how we can help you. Have a great day.