Trauma surgeons want more people trained to assist in mass casualty incidents

May 15, 2014


More than 250 people have been killed in the United States during active shooter and mass casualty incidents since the Columbine High School shootings in 1999. That's according to a Federal Emergency Management Agency document published this past fall to guide fire departments and emergency medical services departments on how best to respond to multiple victims in mass casualty events.

The count of those killed doesn't include the three people who died in April when Spc. Ivan Lopez went on a shooting spree at Fort Hood in Texas before committing suicide; he injured 16 others. It was the second mass killing on that base in recent years, and one of a mind-numbing string of mass murders in the U.S.

Trauma surgeons, federal law enforcement leaders and first responders from around the country who have seen close up the devastating impact of mass casualty incidents, or fear their communities are not immune from the risk of mass violence, met last year in Hartford, Conn. The group, called the Hartford Consensus, hammered out practical steps for communities to take to improve the survival chances of victims. Since many victims die of blood loss before reaching a hospital, one of the group's chief recommendations is that first responders and private citizens be trained in tourniquet use.

The efforts of the Hartford Consensus are having an impact. The American College of Surgeons and the Major Cities Chiefs Police Association, two of the organizations that helped drive the Hartford Consensus, say more than 36,000 police officers in Los Angeles, Philadelphia, Houston, Phoenix, Dallas, New Orleans, Tampa, Fla., and Washington, D.C., will receive bleeding control kits and training this year.

"We want a culture change," said Dr. Lenworth Jacobs, a trauma surgeon and vice president, academic affairs and chief academic officer, for Hartford HealthCare, a multihospital health care system in Connecticut. Jacobs chairs the Hartford Consensus and is a member of the American College of Surgeons Board of Regents, which played a leadership role in forming the group.

Any willing hands
Law enforcement officers are usually first on the scene to an active shooter or mass casualty incident, but they often lack the medical training and equipment to treat victims, the committee said. Members of the Hartford Consensus say that controlling hemorrhage has to be a core law enforcement skill. They also support members of the public receiving training to stanch massive bleeding based on the time-is-critical premise that underlies public training in cardiopulmonary resuscitation or the Heimlich maneuver, Jacobs explained.

The Hartford Consensus group first met on April 2, 2013, just months after the devastating Sandy Hook primary school shootings in Newtown, Conn., and just days before the Boston Marathon bombings last year. While the Hartford Consensus findings were not disseminated at that point, doctors have since said the strong response to stop hemorrhagic bleeding on the scene in Boston, including the use of tourniquets by emergency medical services personnel and others, contributed to lives saved.

The Hartford Consensus call to action stresses that the uninjured should get to safety, if they're able to, or hide if they're unable to escape when there is an active threat. But Jacobs noted that anyone uninjured or minimally injured can act as a rescuer in an emergency, if a person chooses to do so.

When minutes count
The Hartford Consensus calls for every law enforcement officer to have access to tourniquets and dressings for bleeding control and for all law enforcement officers to train in assisting emergency medical services, firefighters and rescue responders in how to evacuate the injured. The Hartford Consensus said it is no longer acceptable to wait for casualties to be brought to the perimeter of the scene. Rather the group recommends that tactical combat casualty care and tactical emergency casualty care concepts be incorporated into emergency medical services, fire and rescue training. These are life-saving techniques and strategies for providing trauma care in the presence of active fire or other danger.

Usually firefighters and emergency medical services workers stage themselves in an area where there is little to no threat, and tend to the wounded once the threat has been removed. However, there's an ongoing discussion among first responder organizations about whether firefighters and emergency medical services personnel should enter "warm zones," or areas of indirect threat in a crisis that have not yet been secured by law enforcement. One approach under consideration would be for first responder organizations in communities to form rescue task force teams to provide wound care in warm zones when there is an ongoing ballistic or explosive threat.

THREAT response
The March issue of the Journal of the American College of Surgeons includes an article called "Hartford Consensus: A Call for Action for THREAT, a Medical Disaster Preparedness Concept." The THREAT acronym was developed to outline the recommended response to mass shooting events: Threat suppression, Hemorrhage control, Rapid Extrication to safety, Assessment by medical providers and Transport to definitive care.

A companion piece, also published in March, calls for a broad educational strategy and an evaluation of the THREAT response to quantify its benefits in the management of active shooter and mass casualty events.

The recent FEMA guide for emergency responders calls the THREAT recommendations for hemorrhage control in mass casualty incidents "very practical" and outlines several ways that fire and emergency medical services agencies should incorporate the THREAT principles. "Experience has shown that the number one cause of preventable death in victims of penetrating trauma is hemorrhage," according to the guide.

Coordinate and prepare
The Hartford Consensus also calls for law enforcement, fire and rescue and emergency medical services to use shared definitions of terms in mass shooting events, jointly develop local protocols to respond to active shooters, and conduct tabletop and field exercises to improve familiarity with the jointly developed protocols.

Some concrete changes are being put into place. For instance, Hartford HealthCare's Hartford Hospital has installed bleeding control bags in public areas throughout the hospital campus. The bags contain gloves; two types of tourniquets; hemostatic dressing, which are bandages treated with agents to accelerate blood clotting; and gauze. Employees and even board members are being trained in how to use the supplies in an emergency, Jacobs said. If a patient or a member of the public is critically injured, even in a hospital, that person's life may depend on stemming blood loss immediately.

Dr. William Marshall, a trauma surgeon at Saint Francis Hospital and Medical Center, a member of Saint Francis Care in Hartford, said he and other physicians and hospital leaders are closely involved in efforts in Connecticut to improve training for the initial response in a mass casualty event.

Marshall, who is not a member of the Hartford Consensus group, is among those working to put its recommendations into common practice. He said at the most recent meeting of the Connecticut State Committee on Trauma, which he attended, trauma medical directors, surgeons and trauma program managers heard updates from speakers about Hartford Consensus topics, like improved response practices that first responders are working on, including better coordination between responding agencies, and bleeding control equipment and training.

Saint Francis Care leadership and staff members, including Marshall, already work with emergency responders to provide peer review and training on trauma care.


Copyright © 2014 by the Catholic Health Association of the United States
For reprint permission, contact Betty Crosby or call (314) 253-3477.

Copyright © 2014 by the Catholic Health Association of the United States

For reprint permission, contact Betty Crosby or call (314) 253-3490.