When 49 people died during the Pulse nightclub shooting on June 12, 2016, it was, at the time, the worst mass shooting in modern U.S. history. But an investigation by public radio station WMFE and ProPublica finds that, if paramedics and firefighters had been allowed inside Pulse earlier that night, the death toll may not have been so high.
In the minutes after the shooting stopped, the shooter was barricaded in a bathroom and victims were piled on top of one another. Orlando police commanders began asking the fire department for help getting shooting victims out of the club and to the hospital.
A few minutes later, the Orlando Police Department's dispatch logs show the police formally requested the fire department to come into the club.
"We're pulling victims out the front. Have FD come up and help us out with that," one officer pleaded.
The Orlando Fire Department had been working on a plan for just such a situation for three years. Like many fire departments at the time, Orlando had long relied on a traditional protocol for mass shootings, in which paramedics stayed at a distance until an all-clear was given.
The department had tasked Anibal Saez Jr., an assistant chief, with developing a new approach being adopted across the country: Specialized teams of medics, guarded by police officers and wearing specially designed bulletproof vests, would pull out victims before a shooter is caught or killed.
After a recommendation from Saez, the department bought about 20 bulletproof vests and helmets. The vests had pouches filled with tourniquets, special needles to relieve bleeding in the chest, and quick-clotting trauma bandages.
None of the equipment was used at Pulse. Emergency medical professionals stayed blocks away from the club. And the bulletproof vests filled with life-saving equipment sat at headquarters.
Bureaucratic inertia
Emails obtained by WMFE and ProPublica lay out a record of opportunities missed. It's not clear whether paramedics could have entered and saved lives. But what is clear is Saez's plan to prepare for such a scenario sat unused, like the bulletproof vests.
His effort had sputtered and was ultimately abandoned after a new fire chief, Roderick Williams, took over the department in April 2015. Williams named another administrator to finalize and implement the new policy. That administrator declined multiple requests to comment for this story.
Saez said he offered to help but never heard back.
"There was a committee that was responsible for the [policy], however, I am not sure whether one was created and approved," one fire official emailed another on March 30, 2016.
In April 2016, two months before Pulse, Chief Williams emailed his deputy chiefs asking for a progress report: "Update on active shooter?" The only response was an email asking if anyone had responded. No one did.
Ultimately 49 people died during the Pulse attack, now counted as one of the worst mass shootings in modern history.
Saez, a 30-year veteran of the Orlando Fire Department, a paramedic and a member of the bomb squad, has been haunted by the possibility that things didn't have to turn out the way they did. "I wonder sometimes if I should've done something else," he said.
"In my mind I'm thinking, 'Man, if I would have had that policy, if I could have got it done, if I could have pushed, maybe it wouldn't be 49 dead. ... Maybe it would be 40. Maybe it would be 48. Anything but the end result here,'" he said.
Survivable wounds
A study published this year in the journal Prehospital Emergency Care concluded that 16 of the victims might have lived if they had gotten basic EMS care within 10 minutes and made it to a trauma hospital within an hour, the national standard. That's nearly one third of victims that died that night.
"Those 16, they had injuries that were, potentially were survivable," said Dr. Edward Reed Smith, the operational medical director for the Arlington County Fire Department in Virginia. He reviewed autopsies of those who died with two colleagues. Smith, whose department was one of the first in the country to allow paramedics into violent scenes with a police escort, has reviewed more than a dozen civilian mass shootings using the same criteria. "How would they be survivable? With rapid intervention and treatment of their injuries."
A separate Justice Department review last year concluded "it would have been reasonable" for paramedics to enter after 20 minutes, a different time frame from the one Smith analyzed.
Orlando's mayor, as well as officials in the police and fire departments, dispute that they could have done anything differently. They say it was impossible to know at the time that there was only one shooter at Pulse or that he wouldn't resume shooting after he barricaded himself in the bathroom. It was also impossible to know whether a bomb threat he later made was real. All of that, they say, would have kept victims from getting care in time.
We're not prepared to go in hot-zone extraction. That's just not what we do as a fire department.
Roderick Williams, the fire chief, said he still believes the inside of Pulse nightclub was a "hot zone," or a place of direct threat, which would have stopped first responders from going in.
"We're not prepared to go in hot-zone extraction. That's just not what we do as a fire department," Williams said. "It was active fire, active shooting."
When can paramedics be sent into harm's way? It's an issue with which law enforcement and fire agencies across the country have struggled. Few departments bring medics in that hot zone. But an increasing number are finding ways to send in specially trained rescue task forces after shooting stops but before the perpetrator is caught or killed. This is called a warm zone operation.
Not everyone who responded that night is sure the Orlando Fire Department had done all it could. They say some victims might have had a chance had the fire department finished the training that it started.
Orlando Fire District Chief Bryan Davis was in charge of his agency's response the night of the Pulse shooting. In an interview, he said his department had done active shooter drills, but it wasn't enough.
"We didn't have formalized training," Davis said. "We didn't have a policy. We didn't have a procedure. We had the equipment [bulletproof vests]. But it was locked up in EMS in a storage closet ...And unfortunately we were a day and a dollar too late. "
Creating an active shooter policy
In 2013, the city of Orlando Fire Department assigned Saez, an assistant chief, to create its active shooter policy.
Saez said he began by using the policy adopted by Arlington County, Va., as the backbone of his draft but stopped when he learned that another group within the fire department was also working on the project. When he tried to merge the two groups together, he was instead told that the other group would handle the policy.
"They were, for a lack of a better word, gun-shy about how aggressive we were gonna get," said Saez, "The whole active shooter thing, it wasn't rocket science, it was common sense."
Then, in 2015, as the FBI was planning a major drill with public safety agencies, Saez said he was again asked to take the lead on the policy. At the time, Fire Chief John Miller was in the process of retiring and Williams, a longtime veteran of the department, had been named to succeed him.
In March, Saez wrote an email to a group of firefighters, including the incoming chief and other high-level administrators as well as medics, "Looks like I got a Dream Team for this Active Shooter Exercise." In the email, he laid out a timeline for getting the policy finalized and an active shooter exercise done in April. He said he was choosing which bulletproof vests and equipment to buy and hoped to train the entire department by the end of the year.
But within a month, Williams was sworn in as fire chief and Saez was sent back to work in a fire station. Such personnel changes are common when a new chief takes over. The active shooter policy was given to another administrator.
Still, in July 2015, the fire department spent $33,000 on 20 bulletproof vests, according to purchase orders obtained by WMFE. Each vest could hold enough supplies to treat 10 to 15 patients. That was enough for each of the five district chiefs working on any given shift to equip a rescue task force.
The policy was never finished, though, and on the night of the shooting, the Orlando Fire Department policy told paramedics to stay three blocks away if they felt "uncomfortable with the scene."
"To know that he could have survived ... "
The gunfire started at 2:02 a.m. on Sunday, June 12, just after last call, and lasted for eight minutes. A call for immediate assistance brought hundreds of officers from 15 police agencies across Central Florida. When the shooting it stopped eight minutes later, Officer Brandon Cornwell of the Belle Isle Police Department and three other officers went inside the Pulse nightclub to kill or arrest the shooter.
They entered through a broken window in the front of the club. The club was dark, lit by pink and blue video screens and disco balls. There was no music playing. Unfinished drinks and unpaid bar tabs littered the tables.
As they got farther inside, a woman could be heard screaming over and over again, according to police body camera video of the scene. Sometimes she screamed for help. Sometimes she just screamed.
The scene was so chaotic, police couldn't figure out who was screaming.
The team walked toward the gunfire and believed it had the shooter cornered in one of the club's bathrooms. They pointed assault rifles and handguns at the doors and hallways to keep the shooter contained.
Officers then started bringing 14 incapacitated victims out of the club. Victims grabbed police officers' ankles as they walked by, according to first responder recollections in the Justice Department report.
People — some dead, some alive — fell stacked on top of one another "like matchsticks." Some victims played dead. Phones rang and rang.
In the ensuing minutes, body camera footage captured the discussion between officers and commanders about getting help.
At 2:23 a.m., a police command officer tried to come up with a way to get paramedics inside. He asked if the shooter's rounds could get into the main area "if we start bringing FD to try to get some of these guys out of here?"
The officer inside responded: "He's got a long gun, so yes, can penetrate," but then said that he was contained in the bathroom and that they had to get the victims out.
A few minutes later, the Orlando Police Department's dispatch logs show the police asked for the fire department "to go in scene secure," meaning dispatchers were asking the fire department to come into the club.
This is about the time, the Justice Department investigation concluded, a rescue task force could have entered the Pulse nightclub.
Still, the fire department did not enter.
"Angry that he's gone"
Laly Santiago-Leon's cousin, Luis Daniel Wilson-Leon was killed in the shooting. She says it's heartbreaking to learn that the fire department put the emergency rescue policy on the backburner. She said she hopes to never learn who the 16 victims with survivable wounds were.
"I'm still, as I said, still angry that he's gone," she said through quiet tears. "But to know that he could have survived would be horrific."
Pulse is no longer the worst mass shooting in the U.S. history. Las Vegas took the mantle last year. Just this year, Florida saw mass shootings at Marjory Stoneman Douglas High School in Parkland and at a video game tournament in Jacksonville.
But Pulse changed the way many law enforcement agencies view the need for a rescue task force. Two weeks after the Pulse nightclub shooting, the upper echelons of the Orlando Fire Department called a meeting.
The topic? "Active shooter project discussion."
Within 10 months, more vests were purchased, and all firefighters had gone through a mandatory 16-hour rescue training course modeled off of the military's approach to field medicine, reworked for civilians. By April 2017 the fire department had an official active shooter policy.
The policy says that firefighters working at certain stations will be called into risky situations, operating as a rescue task force, and that all firefighters may be required to do the same.
But Ron Glass, president of the union representing the Orlando Fire Department, is critical of the new policy. He said the it still doesn't have enough details for emergency medical professionals treating patients. He said if another Pulse happens tomorrow, "we're gonna do the exact same thing again."
"We have a three-inch notebook ... on every type of house fire, every type of specialty, high angle call, below-grade call, extrication call, elevator extrication call," Glass said. "The only thing that's not in the book is ... active shooters."
The Justice Department's Community Oriented Policing Services office, which critiqued the police response to Pulse, has been commissioned by the Fire Department to evaluate its response.
That report is due out soon, and it could give needed closure about the department's response to the Pulse shooting.
"I pray she made it"
Saez, the assistant chief who had been charged with modernizing the department's active shooter policy, was not on duty the night of Pulse. But when his wife, who worked for the Orlando Police Department, texted him about the shooting, Saez remembers driving his hybrid Toyota more than 100 mph to get to the scene.
Saez worked with the arson squad and helped use explosives to breach the outer wall of the club before the shooter was killed. Afterwards, the police dragged a woman to him who had been shot multiple times.
"All I could do was put my hand on her chest to hold pressure and pray, hope ... I hope I did something," Saez said.
An ambulance finally did come and bring the shooting victim to the hospital. Saez doesn't know what happened to her.
"I pray she made it," Saez said.
Saez has filed a hostile work environment complaint with the city of Orlando's human resources department against his immediate supervisor and the fire chief. The city of Orlando said it is "currently reviewing the facts of this case as it is active and ongoing."
Saez said he thinks about the Pulse nightclub shooting every day, and feels responsible for not getting the active shooter protocol pushed through. He has a "sick feeling in the gut."
This story was a collaboration between ProPublica and WMFE, which is a member of theProPublica Local Reporting Network.
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