(AP) When the first paramedics arrived on the scene of the Pulse nightclub shooting, they could still hear gunfire coming from inside the club.
In active-shooting cases, recent federal guidelines call for medics to put on body armor and go into potentially dangerous situations alongside police officers when possible. But paramedics Josh Granada and Carlos Tavarez didn't have bullet-proof vests and they never made it inside the nightclub. Instead, they treated the wounded across the street in the parking lot of a bagel shop.
In all, they made five trips to the emergency room, taking 13 victims to a hospital just a few blocks away. Could they have saved more lives if they had body armor and went inside the gay Orlando nightclub, where 49 people were killed and 53 wounded in the worst mass shooting in modern U.S. history? It's tough to know, they told The Associated Press.
Since the Columbine High School massacre in 1999 in Colorado, paramedics have struggled with how close they should get to active shooter scenes when they know there are wounded victims who need help. The federal guidelines suggest that victims' chances of survival improve when paramedics go into "the warm zone."
Paramedics have traditionally waited for an "all-clear" that it's safe to go into an active-shooter situation. But studies of past mass shootings have shown "the value of having medical and rescue personnel who are properly trained and equipped to enter the warm zone to maximize victim survival," according to a 2014 policy statement from the Federal Emergency Management Agency.
"FEMA therefore encourages first responder agencies to develop this capability," the policy statement said.
At Columbine, some survivors believed a wounded teacher who bled to death over almost four hours could have been saved if he'd been treated earlier. Instead, firefighter-paramedics, as well as many officers, waited to go inside the school. Thirteen people were killed and 24 others wounded.
In the Pulse shooting, paramedic-firefighters stayed out of the danger zone, in part because Omar Mateen indicated to police negotiators that he had explosives, a claim that ended up being false.
"This was a dynamic scene," said Bryan Davis, a district fire chief. "We went from it being a shooter to now we possibly had an explosive device in possession."
When Granada and Tavarez arrived at a fire station a block away from the club, many of the wounded already had fled Pulse. The paramedics said they could hear gunfire and saw people running. They started treating a man who had collapsed with two bullets in his stomach. They drove him to the hospital and headed back.
"We were still the first ambulance on the scene," Granada said. "All the ambulance units at this point were getting set up in the staging area because it was being communicated over our radio that the scene was not secure."
The pair treated club patrons at the fire station and across the street, behind an Einstein Bros. Bagels shop, where police officers had dragged the wounded.
Last summer, Orlando firefighters trained with police officers in active-shooter scenarios where paramedics went into a school and mall alongside the officers. But at Pulse, the priority was setting up treatment areas away from potential gunfire, fire department spokeswoman Ashley Papagni said in an email.
Orlando paramedic-firefighters and ambulance technicians also aren't equipped with body armor or vests, Papagni said.
Going in with a SWAT team member wasn't a good option because Mateen's line of sight "was pretty much everywhere" before he went into a bathroom, and by then, officers were pulling out victims, Granada said.
During Tavarez and Granada's second run, they helped a man whose lungs had collapsed from a gunshot and another who was disoriented and in shock.
"At this point, (the hospital) had nurses and doctors out in the bay with 20 or 30 hospital beds lined up just ready to take patients," Granada said. "I screeched in, parked right there in the bay, I jumped out and unloaded those two."
When they returned, dozens more people on the ground were on the ground at the bagel shop. None could move and "we had pretty much exhausted every single piece of medical equipment," Granada said.
Almost a dozen victims died at or en route to hospitals. Asked whether any could have been saved if paramedics had gotten to them sooner, district fire chief Davis said, "It's really hard to gauge what we could have or could not have done."
He also said the paramedics did their jobs well. "We were there to support law enforcement and as they were bringing us victims and patients, we were transporting them as quickly as we could," he said.