For almost a year now, surgeons and first responder organizations have been working to increase the number of survivors of an active shooter or mass casualty incident. An important part of this initiative requires all law enforcement officers to get medical training and equipment to control bleeding, a goal set forth by the Hartford Consensus, a collaborative group of trauma surgeons, federal law enforcement, and emergency responders, and driven by the American College of Surgeons (ACS), the Federal Bureau of Investigation (FBI), Major Cities Chiefs Association and Prehospital Trauma Life Support program.
The principle of more training and equipment is central to the findings of the Hartford Consensus, according to an article entitled, "The Hartford Consensus: THREAT, A Medical Disaster Preparedness Concept," published in the March issue of the Journal of the American College of Surgeons (JACS). A companion piece to the article also published in the March issue ("Joint Committee to Create a National Policy to Enhance Survivability from Mass Casualty Shooting Events: Hartford Consensus II"), calls for a broad educational strategy and a robust evaluation of the implementation of THREAT in order to quantify its benefits in the management of active shooter and mass casualty events.
THREAT is an acronym for the needed response to mass shooting events developed by the Hartford Consensus: T -- Threat suppression, H -- Hemorrhage control, RE - Rapid Extrication to safety, A -- Assessment by medical providers, and T -- Transport to definitive care. The Hartford Consensus is led by the American College of Surgeons Committee on Trauma and builds on guidelines developed by the U.S. military to advance battlefield trauma care.
Driving the recommendations of the Hartford Consensus is the fact that in active shooter or mass casualty events, victims all too often bleed to death before medically trained emergency responders can reach the scene. The Hartford Consensus, a concept document that came out of the collaborative group's first meeting in April 2013, has received endorsements from key groups across the country, including the Society of Trauma Nurses, American Trauma Society, Major Cities Chiefs Association, and the International Association of Fire Fighters.
Law enforcement officers are typically the first to the scene of such an incident, but they lack the medical training and equipment to treat the victims. Filling that critical need has become one of the central calls to action of the Hartford Consensus, according to the new reports.
"Controlling hemorrhage has to be a core law enforcement tactic," said Alexander Eastman, MD, MPH, FACS, chief of trauma at UT Southwestern/Parkland Memorial Hospital, and Dallas Police Department lieutenant.
"We saw the dramatic impact of this tactic in the Tucson, Ariz. shooting in 2011. With training and tourniquets, law enforcement officers will save lives -- many lives."
The Hartford Consensus is already having an impact: In concert with ACS and the Major Cities Chiefs Association, more than 36,000 police officers in Los Angeles, Philadelphia, Houston, Phoenix, Dallas, New Orleans, Tampa, and Washington, DC, will receive bleeding control kits and training this year, an action rising out of the Hartford Consensus, according to Dr. Eastman. The Hartford Consensus also urges cities to develop an integrated response system, customized to the needs of their community, focused on the importance of initial actions to control hemorrhage as a core requirement of the emergency response.
"We can no longer wait until casualties are brought out to the perimeter," said Lenworth M. Jacobs, MD, MPH, FACS, vice president of academic affairs and chief academic officer and director, Trauma Institute at Hartford Hospital, Connecticut and member of the ACS Board of Regents. "We must prepare responders to safely intervene, control bleeding, and save lives."
Another key call to action of the Hartford Consensus is to educate and equip the public to respond to the need of victims, keeping in mind that sometimes these people, though uninjured or minimally injured, may be victims of the incident themselves. However, activating that type of response effort means that tourniquets and other equipment need to be broadly available in schools, offices, shopping centers, churches, and other public places. Also, education and training programs for what to do in the midst of an active shooter or mass casualty event need to be designed for and made available to the general public.
"Just as automatic external defibrillators are easily usable and quickly available to the public, so should easily applied tourniquets be available in a similar manner and locations," said Norman McSwain, MD, FACS, medical director, pre-hospital trauma life support. "It's not a complicated process and it will save lives."
Active shooter or mass casualty incidents such as the ones at Columbine High School (Littleton, Colo.), Sandy Hook Elementary (Newtown, Conn.), and the Century Movie Theater (Aurora, Colo.) have become a reality of modern American life. But until recently, the responses to these tragic incidents have focused more on law enforcement goals (stop the shooting) than trauma care goals (stop the bleeding). As a result, ACS and the FBI assembled national representatives from medicine, law enforcement, and the military for a meeting in Hartford, Conn. on April 2, 2013 -- just days before the Boston Marathon bombings -- to plan better emergency responses to improve the chance for survival of gunshot and mass-casualty victims.
"We need to expand the pool of first responders," said Michael F. Rotondo, MD, FACS, Chair, ACS Committee on Trauma. "With proper training, under the right circumstances anyone can act as a rescuer."
Recommendations from the initial meeting, the Hartford Consensus I, concluded that the leading cause of preventable death in these incidents was uncontrolled bleeding or hemorrhage. The group met again on July 11, 2013, to improve the continuum of care from the initial response to definitive care. Hartford Consensus II is recommending additional training, education, and equipment for the public -- much like CPR training -- since uninjured bystanders or minimally injured victims would already be on the scene and could respond right away.
In addition, it recommends additional training and education for better coordination and communication among emergency responders, such as law enforcement and emergency medical, fire, and rescue workers. The group cited a wide variety of potential partner organizations that could help implement these new strategies within each state.
- Lenworth M. Jacobs, David Wade, Norman E. McSwain, Frank K. Butler, William Fabbri, Alexander Eastman, Alasdair Conn, Karyl J. Burns. Hartford Consensus: A Call to Action for THREAT, a Medical Disaster Preparedness Concept. Journal of the American College of Surgeons, 2014; 218 (3): 467 DOI: 10.1016/j.jamcollsurg.2013.12.009
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