CHHS Blog: Maximizing Survival

Ambulance (ByCHHS) (2)

July 27th, 2016

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by CHHS Research Assistant Jie Liu

Our nation’s threat from public mass shootings remains elevated. According to a cross-national study of 171 countries, the United States has the most public mass shootings in the world. Between January 2009 and July 2015, there were at least 133 mass shootings in the U.S. The Federal Bureau of Investigation (FBI) defines a mass shooting as an incident where four or more people are killed, which does not include gang killings or slayings that involve the death of multiple family members.

Recently, the typical response to active shooter and mass casualty incidents (AS/MCIs) involves a tactical team first intervening and neutralizing the active shooter(s) or bomber(s) in the “hot zone.” Only after the whole affected area is declared secure does the medical team start to provide care in the “cold zone.” However, numerous studies have demonstrated that accessing patients quickly, providing hemorrhage control promptly, and transporting patients to a hospital setting are critical to saving victims during AS/MCIs. The traditional response approach is very likely to delay any medical treatment needed to control hemorrhaging, and results in more deaths. For example in the 2013 LAX shooting, a Transportation Security Administration (TSA) officer was shot and visible to EMS who was just 150 yards away. However, response protocol did not allow EMS to enter the terminal until the scene was declared safe. Finally, when EMS was allowed to enter, the officer had died after he bled for 33 minutes.

In the recent Orlando shooting case, paramedics could not get into the club because they did not have bullet-proof vests. If they had made it inside the bar, could they have saved more people? After the tragic shooting at Sandy Hook Elementary School, one group, assembled by the American College of Surgeons and the FBI in Hartford, Connecticut, developed a concept document in order to help increase survivability in mass casualty shootings called the Hartford Consensus. The Hartford Consensus currently has four issues.

The Harford Consensus III identifies three levels of responders. The first level is the immediate responders: public or laypeople who are in the same area at the point of wounding, who should perform critical external hemorrhage control prior to the arrival of traditional first responders. The Harford Consensus III recognizes the critical role the immediate responders play in responding to mass shooting and it encourages the public to become involved in the immediate response when safe. The second level is professional first responders, which includes EMS, fire, and police, among others. Professional first responders should first eliminate the shooter/shooters and then control external hemorrhage of victims. All first responders should be trained and have the necessary equipment to provide effective external hemorrhage control. The third level is trauma professionals, like hospitals, whose role begins after victims have been transported away from the scene.

One important approach that the Hartford Consensus and other experts propose for the second level responders is that the professional first responders should treat injured victims at the same time law enforcement secures the area. This approach requires law enforcement to focus on securing access to victims while they are searching for and eliminating shooters, and EMS personnel to respond and operate in a “warm zone” that is dynamically secured, rather than wait for the entire incident area to be absolutely cleared. All traditional first responder organizations, including EMS, fire, and law enforcement, should develop “inter-domain tactics, techniques, and procedures—including the use of ballistic vests, better situational awareness, and application of concealment and cover concepts”—and train the first responders in their use.

The “warm zone” approach is becoming more accepted: recent federal guidelines from the Federal Emergency Management Agency call for paramedics to go into potentially dangerous situations alongside police officers when possible.

In Orlando, the first paramedics arrived on the scene just minutes after the shooting began. However, the first paramedics didn’t have bullet-proof vests, so they never made it inside the nightclub. Rather, they began to treat the wounded across the street, in a parking lot. The fire department sent more than 80 personnel and 34 vehicles, but they were forced to remain outside because getting into the club when the club was still a hot zone “was considered too dangerous.”   While there are new guidelines to help decrease the mortality rate, each situation is dynamic and local responders have to determine how to best respond in each case.

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