WASHINGTON, Oct. 9, 2013 -- All too often, victims of active shooter or mass-casualty incidents bleed to death waiting for medical treatment, according to members of a collaborative group of federal law enforcement, trauma surgeons, and emergency responders who participated in a panel discussion today during the Annual Clinical Congress of the American College of Surgeons (ACS).
Representatives of this collaborative committee, whose recommendations are called the Hartford Consensus, told those attending the panel session, "Mass-Casualty Shootings: Saving the Patients," about workable strategies to help lead their communities and all the different agencies involved in promoting increased victim survival from mass-casualty events. Specifically, they launched a call to action for 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.
"With the recent incidents at the Navy Yard (Washington, DC) and Westgate Mall (Nairobi, Kenya), this topic is very much top of mind," 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. "In one case, emergency responders were delayed 40 minutes because law enforcement didn't want to put them in danger. Most of these shooting events are over in 15 minutes and people can bleed to death within five minutes from these severe injuries. Responses to save victims have to be immediate, fully orchestrated and ready to go, day or night, in any city in the U.S."
Dr. Jacobs continued, "This is everyone's responsibility and everyone - from law enforcement to the public - has to be part of the solution."
Although active shooter or mass casualty incidents such as the ones at Columbine High School (Denver, CO), Sandy Hook Elementary (Newtown, CT), and the Century Movie Theater (Aurora, CO) have become a reality of modern American life, 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 Federal Bureau of Investigation (FBI) assembled national representatives from medicine, law enforcement and the military for a meeting in Hartford, CT 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.
Recommendations from the initial meeting, called the Hartford Consensus I, concluded that the leading cause of preventable death in these incidents was uncontrolled bleeding or hemorrhage.
"The key to improving survival in active shooter mass causality incidents is expanding the pool of first responders," said Alexander Eastman, MD, MPH, FACS, Chief of Trauma at UT Southwestern/Parkland Memorial Hospital, and Dallas Police Department Lieutenant. "Controlling hemorrhage has to be a core law enforcement tactic; this idea is not novel. Many lives were saved in the Tucson, AZ shooting because law enforcement responded and implemented the same techniques the Hartford Consensus is recommending. If you give these officers training and equipment to control bleeding, they will use it; they will use it well, and they will save lives."
As explained at the ACS Clinical Congress, the committee recently made a national call to action to establish first responder protocol to minimize preventable deaths of innocent victims involved in active shooter and mass-casualty incidents. To help achieve this goal, 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.
"Tourniquets should be carried by all law enforcement in their pocket," said, Norman McSwain, MD, FACS, Medical Director, PreHospital Trauma Life Support. "If the American Heart Association can teach the world how to do CPR, the American College of Surgeons can teach the world how to put on tourniquets and control bleeding. It's not a complicated process and it will save lives."
"It is no longer acceptable to stage and wait until casualties are brought out to the perimeter for immediate hemorrhage control," said Michael F. Rotondo, MD, FACS, Chair, ACS Committee on Trauma and co-moderator of the panel session. "We must employ novel approaches to prepare responders to safely intervene, control bleeding, and save lives. Failure to prepare is preparing to fail."
More than 250 people have been killed in the United States during what have been classified as active shooter and mass-casualty incidents since the Columbine High School shootings in 1999, according to a report issued last month by the Federal Emergency Management Agency (FEMA). The report, Fire/Emergency Medical Services Department Operational considerations and Guide for Active Shooter and Mass Casualty Incidents, which serves as a response guide to these incidents for fire and emergency medical personnel, extensively cites the Hartford Consensus recommendations.
"We need to shift the paradigm and draw from the military to improve survivability in the field," said David S. Wade, MD, FACS, Chief Medical Officer, FBI. "This is not just a "big city" issue, it can happen anywhere.
ACS Clinical Congress panelists from the Joint Committee to Create a National Policy to Enhance Survivability from Mass Casualty Shooting Events included:
-- Lenworth M. Jacobs, MD, MPH, FACS, Vice-president, academic affairs,
Hartford Hospital; ACS Board of Regents
-- Michael F. Rotondo, MD, FACS, Chair, ACS Committee on Trauma
-- Norman McSwain, MD, FACS, Medical Director, PreHospital Trauma Life
-- David S. Wade, MD, FACS, Chief Medical Officer, FBI
-- Alexander Eastman, MD, MPH, FACS, Chief of Trauma at UT
Southwestern/Parkland Memorial Hospital, and Dallas Police Department
Other groups involved in the Hartford Consensus but not present at the panel discussion are:
-- William P. Fabbri, MD, FACEP, Medical Director FBI Emergency Medical
-- Frank K. Butler, MD, Chairman, Committee on Tactical Combat Casualty
Care (Department of Defense, Joint Trauma System)
-- John Sinclair, Past-director, International Association of Fire Chiefs
-- Karyl Burns, RN, PhD, Research scientist, Hartford Hospital
-- Kathryn Brinsfield, MD, National Security Staff, Executive Office of the
-- Richard Carmona, MD, FACS, 17th U.S. Surgeon General
-- Richard Serino, Deputy Administrator, Federal Emergency Management
-- Alasdair Conn, MD, FACS, Chief of emergency services, Massachusetts
-- Richard Kamin, MD, CT Department of Public Health, OEMS Medical
Director, American College of Emergency Physicians, Committee for
Tactical Emergency Casualty Care
About the American College of Surgeons
The American College of Surgeons is a scientific and educational organization of surgeons that was founded in 1913 to raise the standards of surgical practice and improve the quality of care for surgical patients. The College is dedicated to the ethical and competent practice of surgery. Its achievements have significantly influenced the course of scientific surgery in America and have established it as an important advocate for all surgical patients. The College has more than 79,000 members and is the largest organization of surgeons in the world. For more information, visit www.facs.org.