Surgeons appeal for change to emergency response protocols

WASHINGTON – A first step to limiting loss of life in mass shooting events is to train law enforcement officers to manage hemorrhaging and ultimately to extend that training to all citizens, a collaborative panel of medical, military, and law enforcement leaders has concluded.

Communities must insist that hemostatic control become a core law-enforcement skill. Rapid hemostatic control has now been shown in several analyses to be critical to the survival of mass-shooting victims, panel members said at the annual clinical congress of the American College of Surgeons.

Whitney McKnight/IMNG Medical Media

"Tourniquets don’t belong on an ambulance. They belong in a policeman’s pocket," said Dr. Norman E. McSwain, a panel member and medical director of PreHospital Trauma Life Support, New Orleans.

"If you give these [law-enforcement] officers the training and the equipment, they will absolutely utilize it and you will see an immediate return on your investment. They will make you proud," added Dr. Alexander Eastman, another panel member who also is interim chief of trauma at Parkland Memorial Hospital in Dallas and a lieutenant on the Dallas Police Department SWAT team.

The recommendation discussed by panelists at the meeting is just one from a collaborative committee that included, among others, high-level representatives from the Department of Defense (DOD), the Federal Bureau of Investigation (FBI), and the Federal Emergency Management Agency (FEMA).

According to Dr. Lenworth M. Jacobs, trauma director and chief academic officer for Hartford (Conn.) Hospital, the committee grew out of the "profound effect" he experienced in reviewing the autopsies of the 26 Sandy Hook Elementary School shooting victims in Newtown. The number of dead was over three times greater than the number of injured victims in that attack and the medical examiner on the case asked Dr. Jacobs to help determine why the survival rate was so low.

Dr. Jacobs, a regent with the American College of Surgeons (ACS), approached the ACS Board of Regents about an initiative to develop community responses to mass shootings, because he felt "something good had to come out of" that tragic event. In response, the board tasked Dr. Jacobs and Dr. Michael Rotondo, who chairs the ACS committee on trauma, with forming a consortium of leaders to help communities better prepare for the worst in an era when civilians have access to military-grade weaponry and explosive devices.

The committee met in Hartford in April 2013 and drafted the Hartford Consensus, based on the group’s shared belief that community leaders should approach mass-casualty events like the combat situations they closely resemble. "We need to shift the paradigm and draw from the military to improve survivability in the field," said Dr. David Stuart Wade, chief medical officer for the FBI.

The committee turned to the DOD’s protocols for Tactical Combat Casualty Care. Predicated on a tightly integrated response to an attack, including the "buddy system" of attending to a fellow soldier’s wounds, the protocols were found to have helped reduce the incidence of preventable deaths from extremity hemorrhage to just 2.6% over the course of a decade (J. Trauma Acute Care Surg. 2012;73:S431-7).

In a subsequent interview, Dr. McSwain cited another study (J. Emerg. Med. 2011;41:590-7) that influenced the committee, showing that greater survival rates in 499 soldiers wounded in battle were associated with the prehospital application of tourniquets (89% vs. 78% hospital), particularly when applied before the onset of shock (96% vs. 4% after).

The group also created the THREAT response model for civilian agencies, taking the three current discrete stages of mass casualty–event response in America – threat suppression, medical assessment, and transport – and overlapping them so that definitive care starts immediately to minimize casualties. THREAT stands for Threat suppression, Hemorrhage control, Rapid Evacuation, Assess patient, Transport to trauma center.

Referring to how law enforcement, emergency medical personnel, and other municipal agencies currently are segmented, with each agency acting according to its own objectives, command structures, and vocabularies, Dr. Eastman said that the THREAT model "is 100% a new paradigm" that can make all municipal disaster responses, regardless of the nature of the tragedy, more efficient. "The Hartford Consensus is designed to make these groups, that previously might not have worked well together, become more integrated than ever," he said.

The committee met again in July to draft the Hartford Consensus II, a call to action for local communities across the country to adapt the THREAT model to their current mass casualty–event response plans or to develop a TREAT-based plan if they don’t have one already. "Failing to plan is planning to fail," Dr. Rotondo said during the panel presentation, of which he was the comoderator. "Think the unthinkable and begin to think how you would respond," he said, advising the audience to "practice what you’ve planned. Go deep into your resources."

The Hartford Consensus II also recommends that tourniquets and other medical equipment be prepositioned in appropriate public locations, similar to how automatic external defibrillators are, and that the public be taught how to use them.

In response to questions about training the public, including school teachers, how to protect themselves and others from an active shooter, Dr. Jacobs responded that the best thing to do is to "run, hide, fight." He stated that the time necessary to hide was typically only 15 minutes before the situation is under control.

"I can tell you that a military-grade bullet, shot at point-blank range into anybody, but especially little people, is devastating," Dr. Jacobs said. The weapon used in the Sandy Hook shooting was a military-style semiautomatic Bushmaster .223 rifle. "While you don’t really want to take on an AK-47 or a Bushmaster," Dr. Jacobs said that if it were necessary to confront the shooter, "be as aggressive as possible."

Surgeons can play a part in ensuring the Hartford Consensus is adopted nationally, said Dr. Wade, by becoming "energized" and meeting with their respective local authorities to discuss ways to protect their communities.

"Be a good citizen," Dr. Rotondo told the audience, suggesting they communicate with other hospitals in their hometowns and develop strong relationships with their local leaders to help prepare for such a disaster. He also mentioned that the ACS committee on trauma is available to the surgical community to help activate change.

The committee’s next step, said Dr. Jacobs, is to work with the entertainment industry to start incorporating the THREAT model into movies and television shows so that a measured response to the type of violence that has become a fact of American life can be modeled for the citizenry.

[email protected]

WASHINGTON – A first step to limiting loss of life in mass shooting events is to train law enforcement officers to manage hemorrhaging and ultimately to extend that training to all citizens, a collaborative panel of medical, military, and law enforcement leaders has concluded.

Communities must insist that hemostatic control become a core law-enforcement skill. Rapid hemostatic control has now been shown in several analyses to be critical to the survival of mass-shooting victims, panel members said at the annual clinical congress of the American College of Surgeons.

Whitney McKnight/IMNG Medical Media

"Tourniquets don’t belong on an ambulance. They belong in a policeman’s pocket," said Dr. Norman E. McSwain, a panel member and medical director of PreHospital Trauma Life Support, New Orleans.

"If you give these [law-enforcement] officers the training and the equipment, they will absolutely utilize it and you will see an immediate return on your investment. They will make you proud," added Dr. Alexander Eastman, another panel member who also is interim chief of trauma at Parkland Memorial Hospital in Dallas and a lieutenant on the Dallas Police Department SWAT team.

The recommendation discussed by panelists at the meeting is just one from a collaborative committee that included, among others, high-level representatives from the Department of Defense (DOD), the Federal Bureau of Investigation (FBI), and the Federal Emergency Management Agency (FEMA).

According to Dr. Lenworth M. Jacobs, trauma director and chief academic officer for Hartford (Conn.) Hospital, the committee grew out of the "profound effect" he experienced in reviewing the autopsies of the 26 Sandy Hook Elementary School shooting victims in Newtown. The number of dead was over three times greater than the number of injured victims in that attack and the medical examiner on the case asked Dr. Jacobs to help determine why the survival rate was so low.

Dr. Jacobs, a regent with the American College of Surgeons (ACS), approached the ACS Board of Regents about an initiative to develop community responses to mass shootings, because he felt "something good had to come out of" that tragic event. In response, the board tasked Dr. Jacobs and Dr. Michael Rotondo, who chairs the ACS committee on trauma, with forming a consortium of leaders to help communities better prepare for the worst in an era when civilians have access to military-grade weaponry and explosive devices.

The committee met in Hartford in April 2013 and drafted the Hartford Consensus, based on the group’s shared belief that community leaders should approach mass-casualty events like the combat situations they closely resemble. "We need to shift the paradigm and draw from the military to improve survivability in the field," said Dr. David Stuart Wade, chief medical officer for the FBI.

The committee turned to the DOD’s protocols for Tactical Combat Casualty Care. Predicated on a tightly integrated response to an attack, including the "buddy system" of attending to a fellow soldier’s wounds, the protocols were found to have helped reduce the incidence of preventable deaths from extremity hemorrhage to just 2.6% over the course of a decade (J. Trauma Acute Care Surg. 2012;73:S431-7).

In a subsequent interview, Dr. McSwain cited another study (J. Emerg. Med. 2011;41:590-7) that influenced the committee, showing that greater survival rates in 499 soldiers wounded in battle were associated with the prehospital application of tourniquets (89% vs. 78% hospital), particularly when applied before the onset of shock (96% vs. 4% after).

The group also created the THREAT response model for civilian agencies, taking the three current discrete stages of mass casualty–event response in America – threat suppression, medical assessment, and transport – and overlapping them so that definitive care starts immediately to minimize casualties. THREAT stands for Threat suppression, Hemorrhage control, Rapid Evacuation, Assess patient, Transport to trauma center.

Referring to how law enforcement, emergency medical personnel, and other municipal agencies currently are segmented, with each agency acting according to its own objectives, command structures, and vocabularies, Dr. Eastman said that the THREAT model "is 100% a new paradigm" that can make all municipal disaster responses, regardless of the nature of the tragedy, more efficient. "The Hartford Consensus is designed to make these groups, that previously might not have worked well together, become more integrated than ever," he said.

The committee met again in July to draft the Hartford Consensus II, a call to action for local communities across the country to adapt the THREAT model to their current mass casualty–event response plans or to develop a TREAT-based plan if they don’t have one already. "Failing to plan is planning to fail," Dr. Rotondo said during the panel presentation, of which he was the comoderator. "Think the unthinkable and begin to think how you would respond," he said, advising the audience to "practice what you’ve planned. Go deep into your resources."

The Hartford Consensus II also recommends that tourniquets and other medical equipment be prepositioned in appropriate public locations, similar to how automatic external defibrillators are, and that the public be taught how to use them.

In response to questions about training the public, including school teachers, how to protect themselves and others from an active shooter, Dr. Jacobs responded that the best thing to do is to "run, hide, fight." He stated that the time necessary to hide was typically only 15 minutes before the situation is under control.

"I can tell you that a military-grade bullet, shot at point-blank range into anybody, but especially little people, is devastating," Dr. Jacobs said. The weapon used in the Sandy Hook shooting was a military-style semiautomatic Bushmaster .223 rifle. "While you don’t really want to take on an AK-47 or a Bushmaster," Dr. Jacobs said that if it were necessary to confront the shooter, "be as aggressive as possible."

Surgeons can play a part in ensuring the Hartford Consensus is adopted nationally, said Dr. Wade, by becoming "energized" and meeting with their respective local authorities to discuss ways to protect their communities.

"Be a good citizen," Dr. Rotondo told the audience, suggesting they communicate with other hospitals in their hometowns and develop strong relationships with their local leaders to help prepare for such a disaster. He also mentioned that the ACS committee on trauma is available to the surgical community to help activate change.

The committee’s next step, said Dr. Jacobs, is to work with the entertainment industry to start incorporating the THREAT model into movies and television shows so that a measured response to the type of violence that has become a fact of American life can be modeled for the citizenry.

[email protected]

WASHINGTON – A first step to limiting loss of life in mass shooting events is to train law enforcement officers to manage hemorrhaging and ultimately to extend that training to all citizens, a collaborative panel of medical, military, and law enforcement leaders has concluded.

Communities must insist that hemostatic control become a core law-enforcement skill. Rapid hemostatic control has now been shown in several analyses to be critical to the survival of mass-shooting victims, panel members said at the annual clinical congress of the American College of Surgeons.

Whitney McKnight/IMNG Medical Media

"Tourniquets don’t belong on an ambulance. They belong in a policeman’s pocket," said Dr. Norman E. McSwain, a panel member and medical director of PreHospital Trauma Life Support, New Orleans.

"If you give these [law-enforcement] officers the training and the equipment, they will absolutely utilize it and you will see an immediate return on your investment. They will make you proud," added Dr. Alexander Eastman, another panel member who also is interim chief of trauma at Parkland Memorial Hospital in Dallas and a lieutenant on the Dallas Police Department SWAT team.

The recommendation discussed by panelists at the meeting is just one from a collaborative committee that included, among others, high-level representatives from the Department of Defense (DOD), the Federal Bureau of Investigation (FBI), and the Federal Emergency Management Agency (FEMA).

According to Dr. Lenworth M. Jacobs, trauma director and chief academic officer for Hartford (Conn.) Hospital, the committee grew out of the "profound effect" he experienced in reviewing the autopsies of the 26 Sandy Hook Elementary School shooting victims in Newtown. The number of dead was over three times greater than the number of injured victims in that attack and the medical examiner on the case asked Dr. Jacobs to help determine why the survival rate was so low.

Dr. Jacobs, a regent with the American College of Surgeons (ACS), approached the ACS Board of Regents about an initiative to develop community responses to mass shootings, because he felt "something good had to come out of" that tragic event. In response, the board tasked Dr. Jacobs and Dr. Michael Rotondo, who chairs the ACS committee on trauma, with forming a consortium of leaders to help communities better prepare for the worst in an era when civilians have access to military-grade weaponry and explosive devices.

The committee met in Hartford in April 2013 and drafted the Hartford Consensus, based on the group’s shared belief that community leaders should approach mass-casualty events like the combat situations they closely resemble. "We need to shift the paradigm and draw from the military to improve survivability in the field," said Dr. David Stuart Wade, chief medical officer for the FBI.

The committee turned to the DOD’s protocols for Tactical Combat Casualty Care. Predicated on a tightly integrated response to an attack, including the "buddy system" of attending to a fellow soldier’s wounds, the protocols were found to have helped reduce the incidence of preventable deaths from extremity hemorrhage to just 2.6% over the course of a decade (J. Trauma Acute Care Surg. 2012;73:S431-7).

In a subsequent interview, Dr. McSwain cited another study (J. Emerg. Med. 2011;41:590-7) that influenced the committee, showing that greater survival rates in 499 soldiers wounded in battle were associated with the prehospital application of tourniquets (89% vs. 78% hospital), particularly when applied before the onset of shock (96% vs. 4% after).

The group also created the THREAT response model for civilian agencies, taking the three current discrete stages of mass casualty–event response in America – threat suppression, medical assessment, and transport – and overlapping them so that definitive care starts immediately to minimize casualties. THREAT stands for Threat suppression, Hemorrhage control, Rapid Evacuation, Assess patient, Transport to trauma center.

Referring to how law enforcement, emergency medical personnel, and other municipal agencies currently are segmented, with each agency acting according to its own objectives, command structures, and vocabularies, Dr. Eastman said that the THREAT model "is 100% a new paradigm" that can make all municipal disaster responses, regardless of the nature of the tragedy, more efficient. "The Hartford Consensus is designed to make these groups, that previously might not have worked well together, become more integrated than ever," he said.

The committee met again in July to draft the Hartford Consensus II, a call to action for local communities across the country to adapt the THREAT model to their current mass casualty–event response plans or to develop a TREAT-based plan if they don’t have one already. "Failing to plan is planning to fail," Dr. Rotondo said during the panel presentation, of which he was the comoderator. "Think the unthinkable and begin to think how you would respond," he said, advising the audience to "practice what you’ve planned. Go deep into your resources."

The Hartford Consensus II also recommends that tourniquets and other medical equipment be prepositioned in appropriate public locations, similar to how automatic external defibrillators are, and that the public be taught how to use them.

In response to questions about training the public, including school teachers, how to protect themselves and others from an active shooter, Dr. Jacobs responded that the best thing to do is to "run, hide, fight." He stated that the time necessary to hide was typically only 15 minutes before the situation is under control.

"I can tell you that a military-grade bullet, shot at point-blank range into anybody, but especially little people, is devastating," Dr. Jacobs said. The weapon used in the Sandy Hook shooting was a military-style semiautomatic Bushmaster .223 rifle. "While you don’t really want to take on an AK-47 or a Bushmaster," Dr. Jacobs said that if it were necessary to confront the shooter, "be as aggressive as possible."

Surgeons can play a part in ensuring the Hartford Consensus is adopted nationally, said Dr. Wade, by becoming "energized" and meeting with their respective local authorities to discuss ways to protect their communities.

"Be a good citizen," Dr. Rotondo told the audience, suggesting they communicate with other hospitals in their hometowns and develop strong relationships with their local leaders to help prepare for such a disaster. He also mentioned that the ACS committee on trauma is available to the surgical community to help activate change.

The committee’s next step, said Dr. Jacobs, is to work with the entertainment industry to start incorporating the THREAT model into movies and television shows so that a measured response to the type of violence that has become a fact of American life can be modeled for the citizenry.

[email protected]