In some countries of the world, there are civil wars, tensions, and criminal gangs rise episodes of aggression. In such backgrounds, the activity of emergency services is really limited and sometimes, dangerous.

We collected the following testimony of a paramedic to such circumstances:

Mexico 2014 –  The Red Cross radio central sends a call, requesting backup to respond a shooting in the road from San Pedro to San Juanito. In that place, the report from the State Police headquarter stated that a group of 5 police units was an ambush by an armed group. These convoys were usually patrolling roads to avoid robberies due to the unstable situation.

The inital call came from the Communication Center from the State Police. This center is located in the capital city and 200 km away from the location reported. There was no initial information about how many casualties were in the location or how the events were developing. No information of situation of threat to the responders and no assurance that the location was secure.

The reported location is 90 km away from our base, but two ambulances were 45 km away in smaller cities on the road. They were contacted directly by local police officials and requested to go immediately to the scene. No more information was provided to them. These units were basic urgencies response only. Each with two EMT´s.
The team leader of these two ambulances had the chance to give me a call with the information that they were on their way, but the communication was lost as soon as the cellular network was out of range.

After this call, 4 ambulances were ready to depart and were waiting for instructions. The departure of these 4 units has been ordered, but no lights or sirens until they reached the next town that was 45 km away.

There were several people from the cartels in strategic locations just spotting any unusual activities and ready to give a call to their bosses. The intention was not to draw attention to the movement of theambulances.
I took the fifth unit along with a paramedic/driver. In the way, I was trying to collect as much information as possible, but due to the differences in radio systems between State Police and us and the lack of connection with the mobile phones, there was no more information provided.
The radio network between the ambulances was also not good in the mountainous terrain that was the place of this ambush, so the first two units were unable to give us an update upon arrival.
With this entire situation, I was tempted to detour the 4 unit convoy to the base in the town where they were heading, but I decided otherwise.

Meanwhile the State Police central was calling to our base in order to get more information, just giving us a hint that the situation was really serious and chaotic, but no information about how many people involved, security situation or if more help was on the way.
At this point, there were two ambulances on scene, four more on its way, around 20 to 25 km ahead of my unit and no information how many Police units.

A little bit before I arrived to the town in the middle of the road, I received a call from the team leader of the first two units, they were heading back with 7 officers wounded. They had the two more serious patients, one in each unit, and were being escorted by six police units, where the rest of the injured officers were being transported. These police units are pickup trucks and the injured officers were transported in the back of them.
The incoming convoy was about to cross with the four units ahead of me, so the instruction was to turn around, stop in the side of the road, and prepare to receive the patients according to triage.

The ambulance I was on, was stopped in a police blockade around 10 km from the contact point. There we were informed that several vehicles were heading to the scene but none of them was identified as law enforcement. So we were told to stay put and wait for the convoy of ambulances.
During the waiting, several vehicles were spotted going directly to the blockade and we were ordered to turn down all the lights. Police officers took cover behind the ambulance, guns ready and very nervous.
My colleague and I were inside the ambulance and with no chance or time to try to get out of it. My only hope was that the big Red Cross painted in the side was respected and not used as a bullseye.

This was only a couple of minutes, but for me was like forever, once the vehicles were closer and the police was able to identify them as part of the responding force, it was again calm. The reason they were not identified, was the same decision I took not to use lights and sirens when they departed.
By then the six ambulances were coming to our location (two of the first response and four that were ahead of us) and we were told that the last one had two patients on it but with minor wounds. So our ambulance was free and we took the tail of the convoy and keep the function as a command unit.

We were escorted all the way to the hospital, and prepare to transport to the State Capital, another 100 km away, to two of the wounded officers.

The only action taken was to avoid call attention to prevent advance notice that we were in route or that the units were going to transport the wounded and in that way avoid a second ambush.
The main dilemma was to respond to the call or let them transport the wounded by themselves. We know at the time that a tactical paramedic was assigned to each squad doing patrolling in remote areas, but we weren’t sure that was the case. The standard protocol mandates to wait until confirmation that the threat to the personnel is under control, I skip this ordering to approach to a possible dangerous scene. The decision was made due to the distance, kind of terrain and the knowledge that lack of immediate response had a direct impact on the possibility of survival of the wounded agents.

I knew at the moment that the cartel members do not have history to attack ambulances, but there is no warranty for that. I did not know the reason that provoked the attack in the first place and therefore there was no way to know if they would look to continue to attack the remaining officers. I was taking decisions on the go. According to the information that was being transmitted to me. And with a lot of faith that our neutrality was respected.
All the personnel behaves in a professional way, responding correctly to every indication given. Even knowing that we were breaching protocol, they understood the responsibility was being taken by me and no disciplinary consequence was going to take place for them.

Every unit was checking the surroundings on the way and give feedback about any unusual event, they kept close proximity one to another and did not lose visual contact at any moment. The hospital was given information during our transport time and was being prepared to receive the injured police officers. The area of this hospital was being secured by the police.
The units did respond to the best information available at the time but was way above the reasonable risk. Since the information about the scene was scarce the risk analysis was poor.
The communication with our base was continuous and updated often. A backup response was being prepared during the time we were on route. There is no psychological support in our chapter. Only a debriefing and a session of analysis of the incident.
Even when we attended shootings with multiple victims in the past, there was always in a safe scene, protected by law enforcement or military personnel.

There is no specific training to deal with these situations with less information, lack of communication and a high risk to the personnel. The decision making was done based on experience more than training.
Potential future consequences of the incident for access and security
The delay caused was due to the lack of resources closer to the scene, the main affectation was to the normal ambulance service provided to the city since most of the resources were sent to this incident. Luckily, there was no mayor affectation.
The quality of the service was according to the type of service, enough resources were dispatched to take care of the number of victims, the technical part was provided efficiently.

No personnel left the organization due to this incident, it, however, limited the future plans that the Red Cross had for that area. A subsidiary chapter was planned and the plan was put on hold until the area is considered safe for emergency services providers. This decision is affecting thousands of people living and traveling in an area that is still unstable. There is no real affectation, neither good or bad, to the actors of the incident. Nevertheless, it provided us a more clear picture of how the area is controlled and what alliances and rivalries are in that zone of the state. That information can be used in future incidents.

The actual consequences of that incident were more training in safe access, reinforce the self-protection in the scene, more communication with the law enforcement agencies. But these training and revised protocols are mostly focused on urban areas, not lonely roads in the middle of nowhere. And mostly based on respect for the institution identification.
Our dispatchers also were trained to get more information, look for alternative means to get information and also to provide information.

The communication with the authorities is difficult, to say the least since every 3 years locally and 6 years state the heads of the departments are changed. And all this process has to start over. In one on one or in the street is easy to identify and to be coordinated, but if the procedures are not the ones being promoted by the top officials or if there is no understanding of how these procedures help to protect the personnel is difficult to implement them.

Even that there was no physical contact between the responders and the cartel group that attacked the police convoy, the threat was always there, and it becomes a very real consideration each time that we received a call for a violent incident, even when no firearms were involved or at least not reported. The response time for these incidents became worst and the quality of service to the victims also suffered.

By the time I finished the last review, two EMT´s have been wounded by firearms in two incidents in the country. None of them have in risk their lives but is a clear message that the service is at risk in these situations.

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