A Tactical Medicine After-Action Report of the San Bernardino Terrorist Incident

Joshua P. Bobko, MD; Mrinal Sinha, BA; David Chen, MD; Stephen Patterson, MD; Todd Baldridge, EMT-P; Michael Eby, MD; William Harris, EMT-P; Ryan Starling, EMT-P; Ofer Lichtman, EMT-P


Western J Emerg Med. 2018;19(2):287-293. 

In This Article

Abstract and Introduction


On December 2, 2015, terrorism landed in Southern California when two perpetrators aligned with the Islamic State (IS), murdered and wounded 38 civilians at the Inland Regional Center of San Bernardino, California. Military tactics from the battlefields of Iraq and Afghanistan became strategies employed by terrorist organizations against civilians and domestic law enforcement agencies,[1] requiring first-responder agencies to adapt rapidly to threats that are often discussed but rarely encountered. We describe systemic lessons that should be applied by medical directors of law enforcement, and fire and emergency medical services (EMS) agencies during a large-scale tactical medicine response.


10:58 A.M - The first 911 call is received, reporting gunshots in the vicinity of the 1300 block of South Waterman Avenue.

10:59 A.M - Call is upgraded to "shots fired" at the Inland Regional Center (IRC) with a description of three suspects dressed in black and carrying assault rifles.

11:00 - Two patrol units from the San Bernardino Police Department (SBPD) are dispatched to the scene.

11:04 A.M - First responding police units are on scene and make entry. At this point the two shooters have departed the building after wounding 36 people, of whom 14 would later die. The initial police teams encounter three deceased victims just outside of the building. Law enforcement quickly clears the ground floor of obvious threats before entering the conference room. Within minutes, local fire and EMS units arrive and stage nearby, and the San Bernardino County Sheriff's Department rescue helicopter begins flying around the IRC.

11:09 A.M - The San Bernardino Police Special Weapons and Tactics (SWAT) Team, which was coincidentally conducting training locally, arrives with a 13-person team, including a SWAT medic. This is the first medical asset to reach the victims. The team medic, after supporting the SBPD SWAT team, performs an initial clearing of the IRC; and begins triaging more than 30 wounded civilians.[2]

11:10 A.M - The Sheriff Department's rescue helicopter lands nearby and offloads two aviation medics. These medics were not wearing their Kevlar® personal protective equipment (PPE). The onboard crew chief takes position as airborne sniper cover.

11:15 A.M - A triage, mass-casualty staging location is established by the tactical commander, and the first floor is reported by SWAT to be secured. This notification triggers the evacuation of the wounded to the triage area. Two deceased victims are transported by law enforcement to a nearby medical center.

11:17 A.M - Trauma centers are notified of the event through ReddiNet, the emergency medical notification system used by all hospitals within the region. Prior to the official notification, a mobile intensive care nurse at Loma Linda had been informed unofficially via a cell phone call from a firefighter dispatched to the scene. Five patients were transported to Loma Linda University Medical Center (LLUMC) and six to Arrowhead Regional Medical Center (ARMC).[3]

The total time elapsed during the shooting itself is less than five minutes. Unknown to the responders at the time, the terrorists had planted an improvised explosive device (IED) – a backpack containing pipe bombs with a crude remote detonator – in the conference room. The IED did not explode. From the authors' first-hand estimates, there were at least 30 additional rescue personnel in the IRC conference room at the same time the IED was present, and prior to the device being made safe.

In all, seven surrounding agencies and four SWAT teams converged on the IRC. All of the critical shooting victims were quickly dispatched to the closest regional facilities: LLUMC, an American College of Surgeons (ACS) Level I trauma center; and ARMC, an ACS Level II trauma center. All of the critically wounded arrived for definitive trauma care within 57 minutes of being wounded. Resident physician conferences were being held at both centers that day, allowing both facilities to rapidly mobilize trauma and critical care resources for potential incoming casualties.

14:00 P.M. - The medical response is further complicated by a bomb threat that was called into LLUMC. While this call turned out to be a hoax, it required a substantial diversion of resources to clear during a day when law enforcement and EMS personnel were already being pushed to their limits.

15:07–15:13 P.M. - Law enforcement personnel conduct a felony car stop, and suspects engage in shootout, which ultimately ends with the death of both suspects.