NIOSH LODD Report On Fatal May 2019 Shooting of Wis. Firefighter

REPORT #F2019-13WI • January 11,
2021
Career Firefighter Killed, a Police Officer and a Civilian Wounded

When They Were Shot During EMS Incident—Wisconsin
Executive Summary
On May 15, 2019, a career firefighter was killed, and a police officer and a civilian were injured after
being shot while on an emergency medical services (EMS) incident involving a patient who overdosed.
The firefighter was part of a three-person crew on engine 9321 that was dispatched along with a
private ambulance company at approximately 5:30 p.m. to the report of a patient who had a seizure on
a public bus at a bus terminal. A police officer was first on scene.
The unconscious patient was successfully treated with naloxone on the bus by a paramedic and
regained consciousness. The patient and responders then exited the bus at 5:47 p.m. A second police
officer arrived after the patient walked off the bus.
The police officers, fire, and EMS crews believed that the naloxone would wear off and were
concerned for the patient’s continued well-being. All of the responders expressed their concerns for the
patient’s well-being to the patient multiple times. Because all of the responders believed the patient
would need additional medical assistance and should be transported to a local hospital for follow-up
medical care, the police officers asked the patient repeatedly if he had anything on his person that
could harm the fire and/or EMS responders. During this conversation, the patient abruptly produced a
concealed handgun and began firing at the responders. Police officers immediately returned fire as they
moved to cover. The fire and EMS crews also ran for cover. The patient/shooter and police officers
exchanged gun fire. One firefighter was shot within 3 seconds of the handgun being produced by the
patient and collapsed while seeking cover. He was found unresponsive approximately 80 seconds later
and treated at the scene and transported to a local hospital where he was pronounced dead. A police
officer was shot while returning gun fire. The patient/shooter took a civilian bystander as a hostage and
continued to fire until the patient/shooter was shot and fell to the ground. The civilian hostage was also
shot. The patient/shooter was secured, provided medical treatment for his injuries and transported to a
local hospital where he was pronounced dead. The wounded police officer was transported to a local
hospital by a fellow police officer. The wounded civilian was transported by ambulance to a local
hospital. Both the wounded police officer and civilian were treated at local hospitals and recovered.
The first gun shot was fired by the patient at 6:09 p.m. This was 39 minutes after the arrival of
emergency responders and 22-minutes after exiting the bus.
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Report # F2019-13
Career Firefighter Killed, a Police Officer and a Civilian Wounded When

They Were Shot During EMS Incident—Wisconsin
Contributing Factors
• Medical Emergency: When firefighters first responded to the scene, the patient (prior to the
shooting) was not breathing adequately and required emergency medical attention. An autopsy
confirmed the patient/shooter had methamphetamine, fentanyl, and 4-anilino-N-phenethyl-
piperidine (4-ANPP, a metabolite of fentanyl or fentanyl analogues) in his system.
• Scene Safety and Situational Awareness: After being revived with intravenous naloxone and
exiting the bus under his own power, the patient produced a concealed handgun and fired at
numerous firefighters, law enforcement, EMS, other workers, and civilians. Prior to the
shooting, police officers made multiple attempts but did not complete a search of the patient.
Key Recommendations
• First responders and agencies who deliver medical assistance to patients who overdose should
train staff on standard operating procedures (SOPs) for naloxone administration, including an
understanding of the objective of naloxone therapy and the possibility, albeit unusual, of
agitation and combativeness from persons after receiving naloxone.
• Fire, EMS, and police departments should take steps to help ensure scene safety including
taking all necessary actions to protect themselves when providing lifesaving care to a patient.
The fire service and standards setting organizations should consider developing scene safety
SOPs and training that provide more detailed guidance on the specifics of keeping first
responders safe while providing lifesaving care to patients.
• Authorities Having Jurisdiction (AHJs) (e.g. municipalities, areas, or departments) should
consider developing SOPs or guides that specify when (1) a patient should receive a pat down
to identify information that might be useful for patient care or identify items that pose a threat
to the patient or responders and (2) a patient might be restrained if the patient poses a threat to
themselves or the responders. These SOPs should specify who determines when a pat down is
necessary and who is authorized to perform it. These SOPs should be operationalized, trained,
and exercised by law enforcement, the fire service, and EMS as part of a Unified Command
response.
The National Institute for Occupational Safety and Health (NIOSH) initiated the Fire Fighter Fatality Investigation and Prevention Program to examine
deaths of fire fighters in the line of duty so that fire departments, fire fighters, fire service organizations, safety experts and researchers could learn from these
incidents. The primary goal of these investigations is for NIOSH to make recommendations to prevent similar occurrences. These NIOSH investigations
are intended to reduce or prevent future fire fighter deaths and are completely separate from the rulemaking, enforcement and inspection activities of any
other federal or state agency. Under its program, NIOSH investigators interview persons with knowledge of the incident and review available records to
develop a description of the conditions and circumstances leading to the deaths in order to provide a context for the agency’s recommendations. The NIOSH
summary of these conditions and circumstances in its reports is not intended as a legal statement of facts. This summary, as well as the conclusions and
recommendations made by NIOSH, should not be used for the purpose of litigation or the adjudication of any claim.
For further information, visit the program Web site at www.cdc.gov/niosh/fire or call toll free 1-800-CDC-INFO (1-800-232-4636).
Page ii
Introduction
On May 15, 2019, a career firefighter was fatally
shot while on an EMS call for a drug overdose on
a public intercity bus (Photo 1). A police officer
and a civilian were also injured.
On June 4, 2019, the fire department contacted

the NIOSH Firefighter Fatality Investigation and
Prevention Program (FFFIPP) and requested
assistance with an independent investigation of
the incident.
On July 8, 2019, a NIOSH Medical Officer in the

Hazard Evaluations and Technical Assistance
Branch, Division of Field Studies and
Engineering; a Senior Industrial Hygienist and
Captain in the U.S. Public Health Service from
the NIOSH Emergency Preparedness and
Response Office; an Investigator/Safety and Photo 1. Incident scene. A career fire-
Occupational Health Specialist and an fighter was killed, a police officer and a
Investigator/Engineer with the NIOSH FFFIPP in civilian were injured after being shot on an
the NIOSH Division of Safety Research traveled EMS incident after a patient who
to Wisconsin to investigate this incident. The overdosed was revived and exited this bus.
NIOSH investigators met with senior staff (Photo 1, courtesy local fire department, bus
officers and representatives of the fire identification markings altered by NIOSH.)
department. The NIOSH investigators met with
and interviewed the career firefighters and fire
department officers and the private EMS ambulance crew involved in the incident. The NIOSH
investigators obtained and reviewed fire department training records, standard operating procedures
(SOPs), incident scene photographs and drawings, training records, and medical records. The police
officers who responded were not available to be interviewed. However, a redacted version of the
official police report was provided from the neighboring police department that investigated the
incident. The neighboring police department also provided redacted body camera footage for review by
NIOSH investigators.
Fire Department
The fire department involved in this incident is a career department consisting of 87 uniformed
members that provide fire suppression and non-transport first responder level, EMS protection. The
fire department employs a total of 96 staff including 4 personnel in administration, 3 personnel in fire
prevention and public education and 2 personnel in resource development and special operations.
There are 6 fire stations located strategically throughout the city that serve a population of
approximately 74,100 in a geographic area of approximately 25 square miles. These 6 stations house 8
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Report # F2019-13

heavy apparatus: 5 engines, 1 ladder truck, 1 Quint, and 1 command vehicle. The department also has
trained personnel that cross-staff a heavy rescue truck, 2 water rescue craft, and a rapid response light
rescue/hazardous materials unit.
The department has one Chief, one Deputy Chief, five Battalion Chiefs with one Battalion Chief on
duty per shift, one Battalion Chief of fire prevention and public education, and one Battalion Chief of
resource development and special operations. The Battalion Chiefs and career firefighters are assigned
to one of 3 shifts that work 48 hours on and 96 hours off duty with a daily staffing of 29 personnel.
The fire department does not utilize chief’s aides or incident command technicians.
In 2018, the department responded to approximately 5030 incidents with approximately 3350 of those
listed as EMS and rescue calls. The fatally injured firefighter responded from a station that responded
to approximately 1400 emergency calls (909 of those were emergency medical service calls and rescue
requests) in 2018.
The department has automatic mutual aid agreements with surrounding jurisdictions for EMS and
structural fires. The department utilizes a county-wide computer aided dispatch system for emergency
incidents in their city and a neighboring city and they also utilize a neighboring computerized dispatch
system for emergency response in those counties. Under the automatic mutual aid agreements, the
department responded to those jurisdictions 96 times in 2018. They also regularly train with those
jurisdictions. The department also participates in the MABAS (Mutual Aid Box Alarm System) for
statewide requests and had 9 MABAS related requests for assistance in 2018.
All members of this department are trained and licensed as either Emergency Medical
Responders/First Responders (EMRs with Advanced Skills), Emergency Medical Technicians-Basic
(EMT-Bs), or Emergency Medical Technicians-Paramedic (EMT-Ps) by the state of Wisconsin. In
2018, the department focused on training plans to upgrade their service to a full Emergency Medical
Technician-Basic service. Emergency medical ambulance service, including transport, Basic Life
Support (BLS), and Advanced Life Support (ALS), is provided by a private ambulance service.
In 2018, the department conducted pre-employment physical and psychological examinations for new
hires and candidates in their promotional processes. All personnel directly involved in firefighting
activities participate in the annual physical fitness testing.
The department reported that it has taken a proactive role in developing health and wellness programs
that address the mental well-being and physical fitness of their firefighters. In 2018, a Health and
Wellness Committee was formed to address the needs of firefighters, including behavioral health.
Several fire department members participated in training on peer support and critical incident stress
management. The department also engaged in wellness presentations with a member of the fire service
trained in peer support and a licensed clinician that specialized in post tramatic stress disorder.
Firefighter health programs are guided by National Fire Protection Association (NFPA) 1582, Standard
on Comprehensive Occupational Medical Program for Fire Departments [NFPA 2018a].
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Training and Experience

The state of Wisconsin requires training for firefighters that meets or exceeds the requirements of
National Fire Protection Association (NFPA) 1001, Standard for Firefighter Professional
Qualifications, [NFPA 2013a] for the topic areas of Firefighter I, Hazardous Materials Awareness,
Hazardous Materials Operations, and First Responder. The state does not require annual recertification.
The fire department involved in this incident has a process that utilizes the local technical college
Public Safety Training Center and a regional fire department hiring process to train and hire
firefighters. The recruits are then required to complete an internal 6-week recruit academy and
successfully complete an 18-month probation period.
A detailed description of the technical college’s Public Safety Training Center as well as the
department’s training location is available in the Appendix A.
In the state of Wisconsin, administration of intranasal naloxone is within the scope of practice for the
EMS provider categories in this fire department [Wisconsin Department of Health Services 2019].
Naloxone for intranasal use is carried on the department’s EMS equipment. The department has a
standard operating guideline for responding to “opiate overdose.” This standard operating guideline
suggests considering the administration of intranasal naloxone in 0.5 mg increments up to a maximum
of 2 mg to unresponsive persons suspected of having an opioid overdose. The standard operating
guideline reminds EMS providers that the objective of naloxone therapy is to “increase respiratory
drive.” It also informs EMS providers of the potential for a patient to become violent after receiving
naloxone.
The career firefighter fatally shot in this incident had 14 years of fire service experience with this
department. Fire department training records indicated that he had received training and certification in
Firefighter I, Firefighter II, Hazardous Materials Technician, Fire Inspector, Fire Officer, Structural
Collapse Technician, Emergency Vehicle Operator, Pump Operator, Aerial Apparatus Operator, Truck
Company Operations, National Fire Academy Responding to Terrorism Basic Concepts, Emergency
Medical Technician (EMT) training and certification, and was a Certified Fire Investigator. The career
firefighter was working on his normal shift at the time of the incident. He was assigned to be the acting
driver/engineer on engine 9321.
Although this incident began as a medical assist call and did not involve a known active shooter when
it initially occurred, the following information describes the fire department’s on-going training and
planning for an active shooter event. The fire department in this incident had an established program
and related policies for a response to an “Active Shooter and Rescue Task Force” event or incident.
This included working with law enforcement agencies and EMS to develop and deliver hands-on
training and equip their personnel with personal protective equipment (PPE). Over the past six-years,
training and equipping of the fire department for an active shooter event resulted in having ballistic
PPE issued for each riding position of all apparatus including the command vehicles. Additionally,
members of the fire department worked collaboratively with law enforcement to provide Tactical
Emergency Casualty Care (TECC) certified paramedics for their Special Weapons and Tactics
(SWAT) Team. In addition to basic fire suppression training conducted in 2018, the department
successfully developed procedures to prepare for a response to an “Active Shooter and Rescue Task
Force” event or incident.
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Equipment and Personnel

Units that initially responded to the report of a seizure on a bus:
• Engine 9321 with three personnel including an officer (lieutenant noted as FF 2), the victim
(noted as FF 1), who was the driver of Engine 9321, and a jumpseat firefighter (noted as FF 3).
• Private ambulance with two paramedics.
• Self-dispatched police officer.
Timeline
The following timeline is a summary of events that occurred as the incident evolved. Not all incident
events are included in this timeline. The times are approximate and were obtained by studying the
dispatch records, audio recordings, witness statements, and other information in the report from the
neighboring police department that investigated the incident. All times are based on the redacted body
camera footage and redacted police report that contained the transit station closed circuit television
footage timeline.
Key:
• LEO: Law Enforcement Officer
• FF: Firefighter
• TS: Transit Station
• CCTV: Closed Circuit Television
EVENT TIME SOURCE
911 medical emergency call received from TS. 17:32:30 LEO 1
A TS employee boarded bus. 17:36:00 TS CCTV
TS security officer boarded bus. 17:36:48 TS CCTV
LEO 1 arrived. 17:42:30 LEO 1
Engine 9321 arrived and crew boarded bus. 17:42:35 TS CCTV
Engine 9321 crew made contact with TS employee and 17:43:00 LEO 1
unresponsive patient.
Firefighter (FF) 3 performed sternal rub. Patient unresponsive. 17:43:27 LEO 1
LEO 1 collected nearby bus riders’ observations. 17:43:45 LEO 1
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FF 2 and FF 3 provided medical attention to patient. 17:43:50 LEO 1
Private ambulance with Paramedic 1 and Paramedic 2 arrived 17:44:15 CCTV

on scene.
LEO 1 contacted his supervisor. 17:45:19 LEO 1
FF 3 advised LEO 1 that the event was related to drugs, not a 17:46:21 LEO 1
seizure as originally reported.
LEO 1 checked garbage in the bathroom of the bus for signs 17:47:15 LEO 1
of drug use.
Paramedic 1 administered naloxone (0.5 mg) intravenously to 17:49:45 LEO 1

patient.
Patient responded to intravenous naloxone but was dazed. 17:50:36 LEO 1
LEO 1 called police supervisor. 17:51:24 LEO 1
Paramedic 1 administered a second dose of naloxone (0.5 mg) 17:51:15 LEO1

intravenously to patient.
LEO 1 called second person (likely police) to explain 17:52:45 LEO 1

situation. Responders continued to talk with patient.
Paramedic advised patient he needed to go to the hospital. 17:54:40 LEO 1
LEO 1 also advised patient that he needed to go to the 17:54:45 LEO 1

hospital.
Patient stated he took his wife’s morphine pills on the bus. 17:56:05 LEO 1
LEO 1 asked Dispatch for a second unit. LEO 2 was 17:56:30 LEO 1
dispatched.
Patient walked off the bus under his own power. 17:57:00 LEO 1
Once patient was off the bus, LEO 1 asked to check patient’s 17:57:20 LEO 1
pockets to make sure he did not have anything sharp.
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Patient sat on cot facing LEO 1 and ignored LEO 1’s request 17:57:21 LEO 1
for a pat down (first request).
LEO 1 asked patient if he could ‘check him out real quick’ 17:57:38 LEO 1
(second request).
Patient asked to stand up. 17:57:39 LEO 1
LEO 1 stated “yes, it would be helpful if you don’t mind if I 17:57:41 LEO 1
pat you down real quick” (third request).
Patient stated, “I have a problem with that”. 17:57:44 LEO 1
LEO 1 asked whether there is “anything on you that can hurt 17:57:49 LEO 1
these guys?” Patient states, “No, Sir.” LEO 1 asked, “how
come you have a problem with that?”
Patient stated, “because I don’t know what I have on me.” 17:57:54 LEO 1
LEO 1 explained to the patient what happened to him and 17:58:00 LEO 1
wanted to triple check (fourth request).
Patient ignored LEO 1 and started to stretch. Patient stated he 17:58:25 LEO 1
took 4 morphine pills prescribed for his wife. Patient turned
his right side away from LEO 1 and up against the front of the
bus.
LEO 1 told patient, “I am going to pat you down” (fifth 17:59:05 LEO 1
statement).
Patient put his hands up to LEO 1 to avoid contact and said, 17:59:07 LEO 1
“Wait, I need to check myself first.”
Patient began emptying his pockets. 17:59:16 LEO 1
LEO 1 asked, “Can I pat you down real quick then?” Patient 17:59:25 LEO 1
ignored this request and continued digging in his pockets.
LEO 1 states “It doesn’t have to be a big deal. I just want to
get you medical treatment” (sixth request).
Patient stated, “I don’t need medical treatment.” 17:59:42 LEO 1
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Patient continued to ignore LEO 1 and Paramedic 1. Patient 18:00:10 LEO 1

stretched again and said his feet hurt.
LEO 1 advised patient to sit on the cot; patient refused. 18:01:04 LEO 1
LEO 2 arrived on the scene. 18:01:30 LEO 1
LEO 2 is briefed by LEO 1 and advised of patient’s refusal to 18:02:10 LEO 2

be patted down.
LEO 2 observed Paramedic 1 and patient. 18:02:13 LEO 1
LEO 1 continued to talk to patient. 18:02:30 LEO 1
LEO 1 called supervisory lieutenant and explained scenario. 18:02:58 LEO 1

Patient continued to state why he “cannot go” to the hospital.
Patient argued with responders about his medical status. 18:03:15 LEO 2
Patient stated he did not need medical assistance.
Patient refused to sit on cot. 18:03:33 LEO 2
Patient stated he preferred not to go to hospital. 18:03:53 LEO 2
Patient stated he did not want to get checked out. Patient 18:04:20 LEO 2
stated that he needed to get home to his wife. Arguing
continued.
Patient was told by responders and transit employee he could 18:04:39 LEO 2
not get back on the bus if he was not medically cleared.
Patient stated he had to get home and pay rent and that his 18:05:27 LEO 2
wife was in the hospital. Patient stated that his feet were
starting to really hurt. TS employee explained he had to be
medically evaluated before he could get back on the bus to go
home.
LEO 2 advised patient to let Paramedics take him to hospital 18:05:35 LEO 2
for an evaluation.
Patient stated his legs had been hurting for a while. 18:06:53 LEO 2
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LEO 1 re-approached patient. 18:06:59 LEO 2
LEO 1 spoke with patient and explained voluntary treatment 18:07:02 LEO 1
versus medical detention involving a Crisis Center evaluation.
Patient again said he “cannot” go to the hospital. 18:07:14 LEO 2
LEO 1 explained to patient why he needed medical attention. 18:07:20 LEO 2
Patient said he took morphine, not opioids. 18:07:50 LEO 2
Patient took deep breaths, crossed his arms, and said, “No, 18:08:11 LEO 1
man.” LEO 1 explained voluntary treatment versus medical
detention involving a Crisis Center Evaluation again.
LEO 2 moved behind to view patient’s body from behind. 18:08:15 LEO 2
LEO 1 again explained voluntary treatment versus medical 18:08:24 LEO 2

detention involving a Crisis Center evaluation.
LEO 2 asked patient, “Real quick, do you have any 18:08:41 LEO 2
weapons?”
Patient responded, “No Sir.” 18:08:42 LEO 2
LEO 2 asked about weapons again and identified a bulge on 18:08:43 LEO 1/ LEO
patient’s right side. 2
Patient stated, “that’s my phone.” 18:08:43 LEO 2
LEO 2 told patient, “don’t reach for it.” 18:08:47 LEO 2
LEO 2 attempted to pat down patient but was physically 18:08:47 LEO 1
grabbed by patient and deflected away.
Patient stated, “I have a problem with officers touching me 18:08:51 LEO 2

man. I get nervous and stuff.”
LEO 1 stated twice “Lift up your shirt then.” 18:08:54 LEO 1
LEO 2 stated “Lift up your shirt then.” 18:08:55 LEO 1
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LEO 1 stated “we want to make sure everybody is safe.” 18:08:59 LEO 1
Patient reached under his shirt with his right hand, flipped 18:08:58 LEO 2
open the phone case.
LEO 1, LEO 2, FF 1, FF 2, FF 3, TS Security Officer, 18:09:00 TS CCTV

Paramedic 1, and Paramedic 2 can all be seen gathered in
front of bus. Patient cannot be seen by this camera.
LEO 2 yelled “Don’t reach! Don’t reach!” 18:09:02 LEO 2
Shooting started. LEO 2 had service weapon drawn and faced 18:09:04 TS CCTV
west. Everyone appeared alert and starting to move. FF 1, FF
3, Paramedic 1, and TS Security Officer moved south. FF 2
and Paramedic 2 moved north.
LEO 2 continued to face west as Paramedic 2 moved north 18:09:05 TS CCTV

and FF 1 moved south. FF 1 had his back exposed to the
shooting.
LEO 2 continued to face west as FF 1 moved to the south with 18:09:06 TS CCTV
his arms near his torso and began to stumble to the concrete.
TS Security Officer entered the TS. 18:09:06 TS CCTV
FF 1 stumbled to the concrete and rolled to the south. His left 18:09:07 TS CCTV
hand was near his torso.
FF 1 tried to get up with both hands near his torso. 18:09:09 TS CCTV
FF 1 lay on his back. LEO 1 moved to the rear of bus on the 18:09:11 TS CCTV
driver’s side with handgun pointed towards the northwest.
LEO 1 notified “shots fired.” 18:09:21 LEO 1
FF 3 went out the door of the TS and pointed toward FF 2 and 18:09:23 TS CCTV
Paramedic 2. FF 3 re-entered building, turned around, and
went back outside. FF 3 then saw FF 1 on the ground and
went toward him.
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FF 3 saw FF 1 and went to him from the northwest entrance of 18:09:44 TS CCTV
the TS and waved FF 2 and Paramedic 2 over to assist.
FF 2 and Paramedic 2 left their cover and ran to FF 3 and FF 18:09:56 TS CCTV
1.
Cardiopulmonary resuscitation was started on FF 1. 18:10:25 TS CCTV
FF 1 was loaded on cot. Cardiopulmonary resuscitation 18:11:40 TS CCTV

continued.
FF 2, FF 3, and Paramedic 2 pushed the cot to north and 18:12:34 TS CCTV

loaded FF 1 onto an ambulance
Ambulance with FF 1 left the scene for the hospital. 18:13:12 TS CCTV
Personal Protective Equipment

At the time of the incident, the victim (FF 1), was wearing his station uniform, bunker pants and boots.
Weather
At approximately 5:30 p.m. Central Daylight Time, the weather in the immediate area was reported to
be approximately 72 degrees Fahrenheit with a dew point of 37 degrees Fahrenheit and relative
humidity of 29%. Wind conditions were 6 miles per hour from the south and partly cloudy with
visibility of 10 miles [Weather Underground 2019]. Weather was not considered to be a contributing
factor in this incident.
Investigation
On May 15, 2019, a career firefighter was fatally shot by a patient who had overdosed (referred to as
“patient” in this report and also “patient/shooter” after opening fire) while on an EMS call. A police
officer and a civilian were also injured after being shot.
At approximately 5:30 p.m., Engine 9321 and a private ambulance company crew consisting of two
paramedics were dispatched to a patient who reportedly had a seizure on a public intercity bus at a
transit station. The Engine 9321 consisted of a crew of 3 firefighters. The victim was a member of this
crew. He was a career firefighter and was working at his normal duty station. A police officer also
responded to the scene to assist the fire and EMS units. He was first on the scene.
Upon arrival at the scene, the responders found the patient seated in the rear of the bus. The patient
was unresponsive. The patient had agonal (abnormal and inadequate) breathing and pinpoint pupils.
Based on this initial assessment, the responders determined that opioid overdose was more likely than
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seizure. The firefighters inserted a nasopharyngeal airway and provided bag-valve-mask ventilation
with oxygen. A paramedic from the private ambulance company inserted an intravenous line. Once
intravenous access was established, a paramedic from the ambulance company administered 0.5 mg of
naloxone intravenously. The patient resumed spontaneous respiration and became responsive to
stimuli. According to the private ambulance company’s patient care report, due to “the lack of practical
extrication methods,” a second 0.5-mg dose of naloxone was given several minutes later “to allow the
patient [to] self-extricate from the bus.” The patient become fully responsive after the second dose of
naloxone. The nasopharyngeal airway and ventilation were discontinued. The intravenous access was
not removed.
The patient and responders exited the bus. A second police officer arrived as the responders and the
patient were discussing transport to a hospital for further evaluation and treatment. The police officers
asked the patient repeatedly if he had anything on his person that could harm the fire and/or EMS
responders and requested to conduct a pat-down. Because the responders believed that the naloxone
would wear off and that the patient would need further emergency medical assistance, they were
attempting to talk the patient into being transported to the local hospital for follow-up medical care
when the patient abruptly produced a handgun. The patient/shooter began firing shots at the EMS and
fire crews and police officers. The EMS and fire crews and police officers ran for cover while the
police officers returned fire. The patient/shooter and police officers exchanged gun fire while the
patient/shooter took a civilian hostage and continued to fire until he was shot and secured in custody.
One firefighter (the workplace victim) was shot and collapsed while running for protection. A police
officer was shot and injured while returning gun fire. The civilian hostage was also shot and injured.
The firefighter was found unresponsive and immediately treated at the scene. The firefighter was
transported to a local hospital by the ambulance that was on scene and was pronounced dead. The
injured police officer was transported to the hospital by a fellow police officer and the civilian was
transported by an additional ambulance to a hospital for care. The police officer and the civilian
subsequently recovered from their injuries. The patient/shooter was provided treatment for his injuries
and transported to a local hospital where he was pronounced dead.
Contributing Factors
Occupational injuries and fatalities are often the result of one or more contributing factors or key
events in a larger sequence of events that ultimately result in the injury or fatality. NIOSH
investigators identified the following items as key contributing factors in this incident that ultimately
led to the fire fighter fatality:
• Medical Emergency: The incident began as a medical emergency in which the patient (prior to
the shooting) was not breathing adequately and required emergency medical attention. An
autopsy confirmed the patient/shooter had methamphetamine, fentanyl, and 4-anilino-N-
phenethyl-piperidine (4-ANPP, a metabolite of fentanyl or fentanyl analogues) in his system.
• Scene Safety and Situational Awareness: After being revived with intravenous naloxone and
exiting the bus under his own power, the patient produced a concealed handgun and fired at
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numerous firefighters, police officers, EMS, transit workers, and civilians. Prior to the
shooting, police officers made multiple attempts but did not complete a search of the patient.
Cause of Death
According to the medical examiner report, the firefighter died from a gunshot wound.
Recommendations
Recommendation #1: First responders and agencies who deliver medical assistance to patients who
overdose should train staff on SOPs for naloxone administration, including an understanding of the
objective of naloxone therapy and the possibility, albeit uncommon, of agitation and combativeness
from persons after receiving naloxone.
Naloxone is a medication that temporarily reverses the effects of opioids. It can be given through an
intranasal spray, into a muscle (intramuscular), under the skin (subcutaneous), or injected into a vein
(intravenous) or the bone marrow (intraosseous). It works by blocking mu-opioid receptors in the body
so opioids cannot exert their effect. Naloxone does not reverse overdoses from other drugs such as
alcohol, benzodiazepines, cocaine, or amphetamines. Naloxone has a serum half-life of 30–90 minutes
[Lynn and Galinkin 2018], which means that it is possible for its effects to wear off before the effects
of some longer-acting opioids wear off. Partly because of this, over 90% of patients in the United
States who receive naloxone from EMS providers are transported to the emergency department for
more definitive treatment [Faul et al. 2017].
The objective of naloxone therapy administration by trained first responders and other medical
personnel is to maintain adequate oxygenation and ventilation without provoking opioid withdrawal
[Lavonas et al. 2015; National Association of State EMS Officials (NASEMSO) 2019]. A technical
expert panel convened by NASEMSO in collaboration with the National Association of EMS
Physicians and the American College of Emergency Physicians does not recommend giving an initial
dose of naloxone sufficient to achieve full consciousness. In addition, repeat naloxone dosing should
be administered only if the initial dose was inadequate or respiratory depression recurs [Williams et al.
2019]. The fire department’s standard operating guidelines recognized this objective by reminding
department members that upon naloxone administration “[patients] may not wake up … we are only
trying to increase respiratory drive.” While the appropriate dose of naloxone is one that will restore
and maintain respiratory function, the ideal dose of naloxone is not known [Lavonas et al. 2015].
Restoring full consciousness is not required for patient safety. Instead, it might precipitate withdrawal
and agitation, reducing both patient safety and first responder safety. Symptoms of acute opioid
withdrawal include irritability and agitation as well as body aches, increased heart rate, nausea and
vomiting, diarrhea, increased tearing, runny nose, sweating, yawning, and goosebumps. Withdrawal
symptoms are unpleasant but by themselves are not life-threatening to the patient [Clarke et al. 2005;
Boyer 2012]. In addition, persons who receive naloxone might be upset that euphoric effects from
opioids were halted [Feldman 2018].
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By reversing the effects of opioids, naloxone might also induce agitation and combativeness by
unmasking the effects of other substances that patients who overdose might have also used. Regardless
of cause, agitation and combativeness after naloxone administration can pose safety concerns to the
patient and first responders [Williams et al. 2019]. In a previous NIOSH health hazard evaluation of
firefighter-EMS providers, 2 of 32 firefighters (4%) who had administered naloxone in the past 12
months as part of their job duties reported being injured on multiple occasions by a patient after
naloxone administration. The incidents involved being kicked or being shoved downstairs or against a
dresser [NIOSH 2017]. In a study of patients who received naloxone from EMS providers, 13%
experienced agitation or combativeness [Belz et al. 2006].
Relevant agency SOPs should be followed in all emergency settings. To the extent feasible, naloxone
therapy should be guided by the goal of respiratory support, and this goal should be incorporated into
applicable SOPs. Since serious side effects from naloxone are very rare and giving naloxone to an
unconscious person not experiencing opioid toxicity is very unlikely to cause further harm,
considerations about dosing should not stop laypersons or first responders from giving naloxone to
reverse opioid overdoses, which are potentially life-threatening.
In this incident, interviews with responders and reviewing the ambulance run report indicated that the
patient was initially unresponsive and had agonal breathing and pinpoint pupils. After an initial 0.5 mg
dose of intravenous naloxone, the patient resumed spontaneous respiration and became responsive to
painful stimuli. A few minutes later, responders decided to give a second dose of naloxone “to allow
[him to] self-extricate from the bus,” which resulted in the patient becoming fully responsive and able
to walk off the bus.
While it is not certain that stopping naloxone administration when the patient resumed breathing could
have prevented the firefighter fatality, fire departments and other agencies that deliver medical care to
patients who overdose should consider additional training on the objectives of naloxone therapy and
the possibility for agitation and combativeness from persons after receiving naloxone. Fire departments
and EMS agencies should also consider revising procedures to reinforce understanding of the objective
of naloxone therapy and the administration of naloxone to meet the objective of respiratory support.
Background on the opioid overdose epidemic
The United States is currently in the midst of a drug overdose epidemic. First responders are likely to
encounter drug overdoses in the course of their work, as shown by the statistics from multiple data
sources outlined below.
First, the number of drug overdose deaths in the United States has been increasing [CDC 2020d,e]. In
2018, there were 67,367 drug overdose deaths, which corresponds to approximately 185 drug overdose
deaths in the United States every day [Centers for Disease Control and Prevention (CDC) 2020a]. This
represented a 50% increase from the drug overdose death rate in 2013, when the current wave of the
opioid overdose epidemic marked by increases in deaths involving synthetic opioids began [CDC
2020c]. Opioids, especially synthetic opioids such as fentanyl and its analogues, are currently the main
driver of drug overdose deaths. Although data from 2018 showed slight declines in the number of drug
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overdose deaths overall [CDC 2020b,c], provisional data suggest that the number of overdose deaths
from all drug and synthetic opioids has increased in 2019 and 2020 [CDC 2020d]. Approximately 70%
of all drug overdose deaths in 2018 involved an opioid [CDC 2020b].
In Wisconsin, 1,075 people died from a drug overdose in 2018, representing a 28% increase from 2013
[Wisconsin Department of Health Services 2020]. Opioids were involved in 78% of drug overdose
deaths in the state in 2018. Since 2013, the number of deaths involving synthetic opioids such as
fentanyl in Wisconsin increased more than six times, from 80 deaths in 2013 to 504 deaths in 2018
[Wisconsin Department of Health Services 2020].
Second, the number of emergency department visits for suspected opioid overdoses has increased
recently. During July 2016–September 2017, the number of emergency department visits for suspected
opioid overdoses increased approximately 30% in the United States and 109% in Wisconsin [CDC
2018a].
Third, the number of EMS calls during which naloxone has been administered has increased [CDC
2018b; Faul et al. 2017]. Based on a national database of EMS events, there was an 82% increase in
the number of patients who received naloxone from 95,012 in 2012 to 173,016 in 2015 [Faul et al.
2017]. Most of the 911 calls that resulted in naloxone administration (83.3%) did not specify drug
ingestion or poisoning as the medical emergency [Faul et al. 2017].
Opioid overdose deaths have been described as occurring in three waves [CDC 2018c]. The first wave
began with increased prescribing of opioids in the 1990s, which was associated with increases in
overdose deaths due to prescription opioids. In the second wave, there were rapid increases in overdose
deaths due to heroin, starting in 2010. The third wave, which began in 2013, corresponds to increases
in overdose deaths involving synthetic opioids. In particular, fentanyl and fentanyl analogues have
been implicated in this third wave, which is currently evolving.
Recommendation #2: Fire, EMS, and police departments and agencies who deliver medical
assistance should develop SOPs that address the possibility of polydrug overdoses.
Recent reports suggest that opioids are commonly used with other substances. A recent analysis found
that deaths from illicitly manufactured fentanyl increased in 2017–2018 and that stimulants were also
present in approximately 60% of opioid-involved deaths [CDC 2019, 2020 a,b,c]. During January–
June 2019, almost one-third of drug overdose deaths involved a combination of opioids and stimulants
such as cocaine, methamphetamine, other illicit stimulants, and prescription stimulants [CDC 2020a].
Among non-fatal drug overdoses treated in emergency departments, the rate of overdoses that involved
both opioids and amphetamines increased from 2018 to 2019 [CDC 2020d]. In addition, among urine
drug tests done as part of routine medical care, the percentage of cocaine-positive and
methamphetamine-positive samples that were also positive for fentanyl increased over time. By 2018,
the percentage of co-positive samples ranged from 7.9% for methamphetamine and fentanyl to 17.6%
for cocaine and fentanyl [LaRue et al. 2019]. Law enforcement data sources also suggest that fentanyl
is being mixed with other drugs such as cocaine and methamphetamine [CDC 2018d]. Acute effects of
stimulants such as cocaine and methamphetamine can be associated with agitation, restlessness, and
anxiety [Aronson 2016; Cruickshank and Dyer 2009].
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In this incident, postmortem toxicology reports for the patient/shooter indicated the presence of
methamphetamine, among other compounds. In general, amphetamines stimulate the central nervous
system. Acute effects of methamphetamine include euphoria, elevated heart rate and blood pressure,
increased alertness, behavioral disinhibition, and anxiety. At higher doses, methamphetamine can
induce psychosis [Cruickshank and Dyer 2009].
The relationship between the patient/shooter’s actions and the presence of methamphetamine detected
on postmortem toxicology cannot be determined with certainty. The presence of methamphetamine
during testing at a single point in time does not indicate that the patient/shooter used methamphetamine
chronically. While some studies suggest an association between methamphetamine use and homicide
[Ellinwood 1971; Stretesky 2009], these studies involved individuals with chronic methamphetamine
use, which is associated with changes in the brain [Cruickshank and Dyer 2009]. While
methamphetamine use might be associated with several mechanisms that may motivate violence, such
as inhibition of cues that normally control behavior, increased arousal, interference with interpersonal
communication, and intensification of emotions, violent behavior is not inevitable even with chronic
methamphetamine use [Sommers and Baskin 2006]. The presence of methamphetamine during testing
at a single point in time does not indicate that the patient/shooter was a chronic methamphetamine
user.
Furthermore, it is not possible to estimate the time of last use or methamphetamine concentration in the
blood or brain prior to death from a postmortem toxicology test. Reasons include uncertainties about
the dose used, timing of last use, route of administration, and rate of drug movement from other parts
of the body into the bloodstream after death, a phenomenon called postmortem redistribution [Logan
2001; Schepers et al. 2003].
Additionally, recognizing the potential for agitation and combativeness from persons who have
received naloxone, fire, EMS, and police departments should develop ways to coordinate responses to
ensure scene safety if necessary. Other recommendations in this report provide guidance on actions
that fire, EMS, and police departments can take to ensure scene and personnel safety.
Recommendation #3: Fire, EMS, and police departments should take steps to ensure scene safety
including taking all necessary actions to protect themselves when providing lifesaving care to a
patient. The fire service and standards setting organizations should consider developing scene safety
SOPs and training that provide more detailed guidance on the specifics of keeping first responders
safe while providing lifesaving care to patients.
Every situation is unique and has the potential to be unpredictable and should be treated as such by all
responders, including the fire service. This event began with providing lifesaving care to a patient.
The situation then very abruptly developed into an incident of workplace violence that resulted in the
death of a firefighter by firearm homicide. Scene safety is critical to every response and should be an
ongoing process throughout every response.
There are many references to scene safety in numerous trade journals for firefighters and EMS
providers. Guidance about scene safety is generally outlined in NFPA 1500 [NFPA 2018a]. NFPA
3000 [NFPA 2018b] provides an outline of what an Active Shooter/Hostile Response (ASHER)
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program should include. There are many different sources and variations of information and training
that responders can receive regarding scene safety. A generic SOP template that could be adapted by
each Authority Having Jurisdiction (AHJ) could be useful to the fire service as well as EMS providers
to help standardize some of this information. The fire service and standard setting organizations should
collaborate to develop best practices and training standards and/or SOPs that provide more detailed
guidance on the specifics of scene safety assessment and the process of re-evaluating a scene as it
changes throughout a response. Such an approach benefits both responders and members of the public.
At a minimum the SOPs should include all local resource capabilities, i.e., agencies and entities such
as law enforcement, fire, EMS, and local hospitals. The SOPs should be based on a current risk
assessment and should provide information on the scope and purpose of the SOP, how the health and
safety of responders will be maintained, a guide for response actions, and mental health and recovery
of the responders after an incident. The AHJ should ensure that plans are developed, maintained,
evaluated by training and exercises, and updated as needed by all fire, EMS and police departments.
In this incident, while the patient was receiving medical assistance on the bus, it was clear that the
scene was safe for law enforcement, firefighters, and paramedics to perform their duties. However, a
scene should be re-evaluated periodically as the situation evolves. After the patient exited the bus
under his own power, two law enforcement officers spoke with the patient about the need to determine
if he had anything on him that could harm the paramedics or firefighters at the scene when they
transported him to the hospital for further medical evaluation. This was part of the ongoing scene
safety assessment.
In addition to the two law enforcement officers performing a scene safety assessment, there were two
private ambulance company paramedics, three firefighters, two transit station employees, and one bus
driver within several feet of the patient. Therefore, a total of 10 people were working within a few feet
of the patient before this phase of the scene safety assessment was complete. Of those 10 workers, it
appears that everyone except the bus driver was actively engaged in the conversation with the patient
or monitoring the situation. (The bus driver did not engage the patient; he was preparing to back the
bus away from the scene when shots were fired.)
In this incident it was clear from the multiple requests by law enforcement to search the patient that the
responders did not know if the patient had anything on his person that could harm the patient or the
responders. During the interviews, some of the fire and EMS responders indicated they stayed near the
patient in order to either provide further medical assistance to the patient and/or to assist law
enforcement. Fire department company officers and unit leaders should help to ensure that while some
of the responders may need to be in close proximity of the patient, they may not all need to be. All of
the responders should be aware of and act in their specific roles as needed by each event.
Given that any situation can change rapidly, unit or company officers should continually alert their
crews to threats and position crews accordingly. There should be an ongoing assessment of an incident
until the incident is determined to be under control. It is prudent to limit the number of firefighters,
EMS providers, and other workers who are not actively engaged in scene safety assessment or patient
care to be in close proximity until law enforcement has been able to determine if the scene is secure
and safe.
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Scene Safety Background
Additional information from the annex of NFPA 1500 Standard on Fire Department Occupational
Safety, Health, and Wellness Program states that:
• Fire department members should not enter an environment where there is ongoing violence, or
the threat of violence such as a person with weapons, without coordination with law
enforcement personnel. This does not necessarily limit the ability of cross-trained fire/law
enforcement personnel or specialty trained EMS providers from entering a violent scene to
assist the law enforcement or fire department responders.
• Such situations include but are not limited to civil unrest, fights, violent crimes, drug-related
situations, family disturbances, persons with altered mental status, and people interfering with
fire department operations.
• The Firefighting Resources of California Organized for Potential Emergencies (FIRESCOPE)
has developed ICS-701, Emergency Response to Tactical Law Enforcement Incidents
[Firescope 2015], which might be useful in developing a standard operating procedure as per
NFPA 1582 [NFPA 2018a].
Incidents that appear routine in nature can turn into a violent or hostile environment after the arrival of
responding crews. A standard communication phrase, known only by communications personnel and
other responders, can warn others of the dangers of the situation without triggering violence or
hostilities. The “Mayday” or emergency button on a portable radio can also be used for responders to
gain attention in a rapidly changing or escalating event. In many of the newer portable radios, once
depressed, the emergency button provides an open airway (without the need for the responder to push a
transmit button) for a number of seconds followed by a priority transmitting availability. This
emergency button activates a signal at the emergency communications center requiring an action by a
dispatcher.
The Essentials of Fire Fighting and Fire Department Operations defines situational awareness as “an
awareness of the immediate surroundings” [IFSTA 2013]. All emergency responders operating at an
incident need to maintain situational awareness and conduct a continuous risk assessment throughout
the incident, reporting unsafe or changing conditions to the incident commander. Firefighters and
emergency responders need to understand the importance of situational awareness and personal safety
on the fireground.
On any emergency scene, every responder should be trained in situational awareness to be constantly
alert for changing and unsafe conditions and be trained to avoid complacency. Situational awareness is
a cognitive learned skill and it can be taught [NIOSH 2018]. This applies not only to conditions found
directly related to the emergency scene (i.e., crash scene), but other hazards and dangers to the
responder(s) from outside events or unsafe conditions or hostile environments. In order to have
situational awareness, you must be able to perceive the threat, comprehend the threat, and predict what
effect that threat may have on you. These elements—Perceive, Comprehend, and Predict—form the
cornerstone of maintaining complete situational awareness [Brennan 2009, Gasaway 2013].
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Recommendation #4: Authorities Having Jurisdiction (AHJs) (e.g. municipalities, areas, or

departments) should consider developing SOPs or guides that specify when (1) a patient should
receive a pat down to identify information that might be useful for patient care or identify items that
pose a threat to the patient or responders and (2) a patient might be restrained if the patient poses a
threat to themselves or the responders. These SOPs should specify who determines when a pat down
is necessary and who is authorized to perform it. These SOPs should be operationalized, trained,
and exercised by law enforcement, the fire service, and EMS as part of a Unified Command
response.
Conducting pat downs when warranted is an important part of patient care and scene safety
assessments. Pat downs may reveal information that can more quickly identify potential causes of the
medical issue (e.g., finding a bottle of nitroglycerine tablets in the patient’s pocket) or provide other
information that is important for patient care (e.g., medical alert bracelet or emergency contact
information). Pat downs may also reveal an item that can be immediately harmful, such as a weapon
(e.g., knife or firearm) as well as items that can inadvertently be harmful to responders (e.g., a sharp
object such as a needle). A risk assessment should be performed to determine if a pat down is
appropriate according to the AHJ’s laws and SOPs. Identifying a potential harm to the patient or
responder can save the life of the patient, first responder, or both.
In this incident, the police were attempting to perform a search of the patient when the patient
produced a concealed handgun and fired at the first responders. If permissible under the AHJ’s laws
and SOPs, one possible option could have been to perform a pat down of the patient after life-saving
therapy was performed on the bus (e.g., airway management and administration of the first dose of
naloxone), but before he was able to walk off the bus on his own power without his weapon being
secured by law enforcement.
While some practitioners recommend the use of physical restraints before naloxone administration to
protect patients and EMS providers [Gaddis and Watson 1992], most patients do not become agitated
or combative after naloxone therapy. Fire and EMS departments should carefully weigh considerations
such as patient distress associated with being restrained upon reversal with naloxone, respect for
patient dignity and patient rights, and other concerns against the likelihood of agitation and
combativeness that would result in patient or EMS provider injury in their restraint protocols to guide
restraint use on a case-by-case basis.
Recommendation #5: Public or mass transportation companies should consider equipping their
terminals/stations with transfer/evacuation devices that are capable of fitting down the aisles for
patient removal.
A public or mass transportation company’s emergency evacuation plan should include provisions for
assisting personnel in moving people who have mobility issues. Numerous states have adopted
legislation that requires building owners or operators to provide a means of egress for people with
mobility impairments with minimum risk to the staff and the individual with impairments. Often this is
accomplished by utilizing a transfer chair (see Photo 2). The general dimensions of transfer chairs vary
but they are designed to fit narrow aisles on aircraft when assisting mobility impaired individuals on a
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daily basis. Evacuation sleds or blankets could be another consideration for safely removing a mobility
impaired patient depending on circumstances.
In this incident, the patient was unconscious and sitting in a window seat on the bus. The patient was
above average in size and weight and there were concerns about being able to move him safely off the
bus. The patient was brought out of his unconscious state primarily so that he could ambulate off the
bus. If a narrow space transfer chair had been available, either on the bus or at the transit station, it
may have been able to be used in the narrow aisle. The wheelchair hydraulic lift on the bus may have
been able to be used to get the patient off the bus, thus avoiding administration of the second dose of
naloxone.
Photo 2. An example of a transfer chair ready for use in a transportation terminal. (Photo by ©
Kukota, Kateryna 2020/Getty Images).
Note: Although there is no evidence that the following recommendation would have prevented this
fatality, it is being provided as a reminder of best practices for the fire service and other public safety
agencies.
Recommendation #6: Fire, EMS, police departments and dispatch agencies should ensure that all
responders have the information needed for their response and safety.
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All agencies receiving calls for assistance should ensure important information for the response and
responder safety is asked during the call taking process and that information is transferred into the
dispatch and communicated to individual responding units. Critical information, such as the suspected
presence of weapons, that can assist first responders with their safety needs, should be obtained and
transmitted to all of the responding units to an emergency if known. This information can help
establish the proper response urgency and prepare responders to more fully consider their own safety
[NIOSH 2005, 2016]. It may also be a communication benefit to relay this information by radio as well
as putting notes in the warning or information section of the Mobile Data Terminal (MDT).
Firefighters and EMS providers may not be sitting in front of an MDT or be able to scroll through and
read important case notes such as this during an emergency response. These important messages
should have a priority screen presence with some sort of visual stimuli to ensure it is noticed. This is
not only important for the primary units assigned, but also fire department and EMS supervisors for
those units.
When sensitive information cannot or should not be transmitted over the radio, the dispatcher should
verbally prompt responding units to check and acknowledge case notes to complete the
communications loop.
In this incident, the communications center received a call for assistance for a patient who reportedly
had a seizure. There were no signs of a hazardous or dangerous scene, nor were there any indications
of the patient being armed with a handgun. Given the information available at the time, the responding
fire engine, ambulance crew, and police officers had no reason to expect that the patient was armed
with a handgun based upon the information provided in the call.
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departments, 2018 edition. National Fire Protection Association, Quincy MA.
NFPA [2018a]. NFPA 1500 Standard on Fire Department Occupational Safety and Health Program,
2018 edition. National Fire Protection Association, Quincy MA.
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Program, 2018 edition. National Fire Protection Association, Quincy MA.
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Health, DHHS (NIOSH) Publication No. 96-100, https://www.cdc.gov/niosh/docs/96-100. Date
NIOSH [2005]. Career lieutenant killed and fire fighter injured by gunfire while responding to medical
assistance call – Kentucky. Morgantown, WV: U.S. Department of Health and Human Services,
Centers for Disease Control and Prevention, National Institute for Occupational Safety and Health,
F2004-11. https://www.cdc.gov/niosh/fire/reports/face200411.html. Date accessed: October 2020.
NIOSH [2014]. Shift safety officer falls through hole in floor into basement of a vacant row house and
dies from smoke inhalation – Maryland. By Merinar T., Loflin M. Morgantown, WV: U.S. Department
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NIOSH [2016]. Career fire fighter killed and volunteer fire fighter seriously wounded when shot
during a civilian welfare check – Maryland. By Miles S.T., Merinar T. Morgantown, WV: U.S.
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Institute for Occupational Safety and Health, F2016-06.
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job stress, and bloodborne pathogens. By Wiegand DM, Chiu S. Cincinnati, OH: U.S. Department of
Health and Human Services, Centers for Disease Control and Prevention, National Institute for
Occupational Safety and Health, Health Hazard Evaluation Report 2017-0021-3293,
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October 2020.
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[2019]. Evidence-based guidelines for EMS administration of naloxone. Prehosp Emerg Care
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Investigator Information
This incident was investigated by Stephen T. Miles, Investigator/Safety and Occupational Health
Specialist, and Matt Bowyer, Investigator/General Engineer with the Firefighter Fatality Investigation
and Prevention Program, Surveillance and Field Investigations Branch, Division of Safety Research,
NIOSH located in Morgantown, West Virginia. Additional NIOSH investigators and report co-authors
were Dr. Sophia Chiu, Medical Officer, Hazard Evaluations and Technical Assistance Branch,
Division of Field Studies and Engineering in Cincinnati, Ohio, and CAPT Jennifer Hornsby-Myers,
industrial hygienist, U.S. Public Health Service, NIOSH Emergency Preparedness and Response
Office in Morgantown, West Virginia.
Page 25
Report # F2019-13

An expert technical review was provided by Matthew Tobia, Fire Chief with the City of Harrisonburg,
Virginia Fire Department. Chief Tobia is a thirty-year student of the fire service and past Chair of the
of the International Association of Fire Chiefs Safety, Health and Survival Section.
A technical review was also provided by the National Fire Protection Association, Public Fire
Protection Division.
Disclaimer
Mention of any company or product does not constitute endorsement by the National Institute for
Occupational Safety and Health (NIOSH), Centers for Disease Control and Prevention. In addition,
citations to websites external to NIOSH do not constitute NIOSH endorsement of the sponsoring
organizations or their programs or products. Furthermore, NIOSH is not responsible for the content of
these websites. All web addresses referenced in this document were accessible as of the publication
date.
Appendix A. Detailed description of the Public Safety Training Center.
The Public Safety Training Center sits on 80 acres of land leased from the airport. This training center
serves law enforcement, fire protection, and EMS professionals. The $34.5 million project was made
possible through a partnership with the AHJ airport and was funded through a district-wide
referendum. It includes the following major elements:
• A 96,000 square-foot tactical lab and classroom building, which includes two indoor firing
ranges, defensive tactics rooms, a fully equipped forensic laboratory, jail training area, EMS
classrooms with an ambulance simulator, computer/dispatch laboratory, and an apparatus bay
containing five double bays including a high bay for aerial trucks.
• A full emergency vehicle operation (EVOC) range with skid pad, skills pad, and pursuit
track.
• Simulated village containing streets, intersections, two full-size residential homes and three
commercial venues: gas station/convenience store, drive-up bank, and hotel/motel/bar. An additional
building is designed for training forced entry, search and rescue, and tactical clearing.
• Comprehensive fire training ground, including a 6-story live burn tower, ladder training
structure, numerous gas- or propane-fired props (e.g. car fire, residential and commercial gas meter
fire, etc.), and technical rescue training facilities, including trench rescue, confined space and high- and
low-angle rescue.
• A decommissioned Boeing 727 to be used for training on-board emergencies, such as

medical emergencies, disruptive passengers, hostage situations, and so forth. A 3-car tank car
simulated derailment to train response to hazardous material release.
Page 26
Report # F2019-13

• Four fully baffled outdoor firing ranges, including 50-yard, 100-yard, and a 300-yard sniper
range with elevated platform.
• Currently under construction is a $14 million addition in the form of an Aircraft Rescue and
Fire Fighting (ARFF) live-burn training facility. When complete, it will contain an administrative
building with two classrooms, three-bay apparatus room and a propane fueled aircraft frame (B-777)
with multiple burn scenarios.
The fire department has a fire training site located at station 6 (also designated as the Special
Operations Station). It houses most of the city’s hazardous materials response capability along with
their tactical hands-on training grounds. It contains county-wide assets that include an all-terrain
vehicle and foam trailer. The Resource Development and Special Operations Division is located at
Station 6 and under the direct supervision of a Battalion Chief. The division also includes a Training
and Resource Development Specialist to assist in the day-to-day operations of the division.
The tactical training grounds consist of a 4-story concrete training tower. The building was developed
to provide different building elevation on each side of the structure; including residential and
commercial appearances. The facility is not designed for live fire but is able to provide simulated
smoke conditions and utilize a Digital Fire Attack System which allows firefighters to locate and
extinguish a simulated fire. There are additional venues that allow for ground and aerial ladders,
ventilation, forcible entry, confined space rescue, rope rescue, building shoring, lifting and moving and
concrete breeching.
In 2018, the department’s division of training oversaw the annual basic skills assessment training that
every member in the operations division completed. The division also oversaw the monthly safety
committee facilitation and monthly training for firefighter, driver/engineer and company officer
training. In 2018, the department recorded 12,558 hours of training. Annually, the department
internally delivers a 6-week recruit fire academy for probationary firefighters. This academy is held at
the training facility at Fire Station 6 and utilizes the Technical College’s Public Safety Training Center
for live burn and other specialty venues. Instructors in the academy include fire operations personnel
assigned to fire stations throughout the city. Academy curriculum includes an orientation, lessons in
fire behavior, the use of extinguishers, study of tools and equipment, discussions on communications
and department policy, instruction on the use of ropes and knots, extensive training on personal
protective equipment (PPE) and self-contained breathing apparatus (SCBA).
The academy utilizes classroom and practical training in ladders, fire hose, water supply, fire streams,
forcible entry techniques, ventilation, search and rescue, salvage and overhaul, self-survival, and fire
tactics. Members of the Fire Prevention and Public Education Division teach classes on fire detection
and alarm systems, pre-plans, the basics of fire prevention, and about the many fire prevention and
safety programs the department offers. The Special Operations Division teaches courses and practical
evolutions in the areas of rope rescue and mechanical advantages, confined space rescue, hazardous
materials response, and special equipment and techniques used in special operations.
In 2018, 31 department members trained at a higher level of water rescue and served as swift water
rescue team members and rescue boat operators. Twenty-eight department members are designated as
Page 27
Report # F2019-13

swift water technicians. All members of the operations division receive annual in-the-water refresher
training for water and ice rescue.
Page 28

NIOSH LODD Report On Fatal May 2019 Shooting of Wis. Firefighter

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NIOSH LODD Report On Fatal May 2019 Shooting of Wis. Firefighter

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REPORT #F2019-13WI • January 11,

Career Firefighter Killed, a Police Officer and a Civilian Wounded

Career Firefighter Killed, a Police Officer and a Civilian Wounded When

On June 4, 2019, the fire department contacted

On July 8, 2019, a NIOSH Medical Officer in the

Career Firefighter Killed, a Police Officer and a Civilian Wounded When

Career Firefighter Killed, a Police Officer and a Civilian Wounded When

Training and Experience

Career Firefighter Killed, a Police Officer and a Civilian Wounded When

Equipment and Personnel

EVENT TIME SOURCE

911 medical emergency call received from TS. 17:32:30 LEO 1

A TS employee boarded bus. 17:36:00 TS CCTV

TS security officer boarded bus. 17:36:48 TS CCTV

LEO 1 arrived. 17:42:30 LEO 1

Engine 9321 arrived and crew boarded bus. 17:42:35 TS CCTV

Firefighter (FF) 3 performed sternal rub. Patient unresponsive. 17:43:27 LEO 1

LEO 1 collected nearby bus riders’ observations. 17:43:45 LEO 1

Career Firefighter Killed, a Police Officer and a Civilian Wounded When

FF 2 and FF 3 provided medical attention to patient. 17:43:50 LEO 1

Private ambulance with Paramedic 1 and Paramedic 2 arrived 17:44:15 CCTV

LEO 1 contacted his supervisor. 17:45:19 LEO 1

Paramedic 1 administered naloxone (0.5 mg) intravenously to 17:49:45 LEO 1

Patient responded to intravenous naloxone but was dazed. 17:50:36 LEO 1

LEO 1 called police supervisor. 17:51:24 LEO 1

Paramedic 1 administered a second dose of naloxone (0.5 mg) 17:51:15 LEO1

LEO 1 called second person (likely police) to explain 17:52:45 LEO 1

Paramedic advised patient he needed to go to the hospital. 17:54:40 LEO 1

LEO 1 also advised patient that he needed to go to the 17:54:45 LEO 1

Career Firefighter Killed, a Police Officer and a Civilian Wounded When

Patient asked to stand up. 17:57:39 LEO 1

Patient stated, “I have a problem with that”. 17:57:44 LEO 1

Patient began emptying his pockets. 17:59:16 LEO 1

Patient stated, “I don’t need medical treatment.” 17:59:42 LEO 1

Career Firefighter Killed, a Police Officer and a Civilian Wounded When

Patient continued to ignore LEO 1 and Paramedic 1. Patient 18:00:10 LEO 1

LEO 2 arrived on the scene. 18:01:30 LEO 1

LEO 2 is briefed by LEO 1 and advised of patient’s refusal to 18:02:10 LEO 2

LEO 2 observed Paramedic 1 and patient. 18:02:13 LEO 1

LEO 1 continued to talk to patient. 18:02:30 LEO 1

LEO 1 called supervisory lieutenant and explained scenario. 18:02:58 LEO 1

Patient refused to sit on cot. 18:03:33 LEO 2

Patient stated he preferred not to go to hospital. 18:03:53 LEO 2

Career Firefighter Killed, a Police Officer and a Civilian Wounded When

LEO 1 re-approached patient. 18:06:59 LEO 2

Patient again said he “cannot” go to the hospital. 18:07:14 LEO 2

LEO 1 explained to patient why he needed medical attention. 18:07:20 LEO 2

Patient said he took morphine, not opioids. 18:07:50 LEO 2

LEO 1 again explained voluntary treatment versus medical 18:08:24 LEO 2

Patient responded, “No Sir.” 18:08:42 LEO 2

Patient stated, “that’s my phone.” 18:08:43 LEO 2

LEO 2 told patient, “don’t reach for it.” 18:08:47 LEO 2

Patient stated, “I have a problem with officers touching me 18:08:51 LEO 2

LEO 1 stated twice “Lift up your shirt then.” 18:08:54 LEO 1

LEO 2 stated “Lift up your shirt then.” 18:08:55 LEO 1

Career Firefighter Killed, a Police Officer and a Civilian Wounded When

LEO 1, LEO 2, FF 1, FF 2, FF 3, TS Security Officer, 18:09:00 TS CCTV

LEO 2 yelled “Don’t reach! Don’t reach!” 18:09:02 LEO 2

LEO 2 continued to face west as Paramedic 2 moved north 18:09:05 TS CCTV

TS Security Officer entered the TS. 18:09:06 TS CCTV

LEO 1 notified “shots fired.” 18:09:21 LEO 1

Career Firefighter Killed, a Police Officer and a Civilian Wounded When

Cardiopulmonary resuscitation was started on FF 1. 18:10:25 TS CCTV