Mass Casualty Incidents, Terrorism & Active Shooter

Leveraging Bystanders as Medical Force Multipliers during MCIs

Issue 8 and Volume 41.

From widespread natural disasters to targeted violence and coordinated terrorist attacks, the threats in our society continue to evolve and become increasingly more complex. Historically, the standard emergency response to large-scale, high-consequence events has been firmly based on the concepts of rapid availability and technical expertise of public safety agencies.

The historic medical response paradigm to these types of events relies solely on medically trained public safety providers as the mitigation strategy for medical care in complex, high-threat incidents. However, at least from a medical perspective, this focus on professional first responders as the mitigation strategy has created a potentially dangerous community-wide dependence on an intact and immediately present EMS structure.

Too often, this overreliance leads to complacency within our communities that makes an assumption that we can handle whatever is thrown at us.

Unfortunately, immediate availability isn’t always the case, leading to delays and breakdowns in the continuum of care.

Given this perspective, this article takes the position that the historic emergency medical response paradigm to complex, high-consequence, high-threat events should be reconsidered.

EMS leveraging bystanders as medical force multipliers during MCIs
Bystanders help an injured person after an explosion at the 2013 Boston Marathon.
AP Photo/The Daily Free Press, Kenshin Okubo

Force Multipliers

Well-publicized events over the past several years, from the Aurora, Colo., movie theater shooting to the nightclub shooting in Orlando, have focused the attention of national policymakers and citizens alike on what many in the first response community have known for quite some time: Uninjured or minimally injured bystanders can and will act to assist others. These bystanders can actually be the “first care providers” and can be effective force multipliers in the emergency response to these incidents.

This action can be attributed to the Social Identity Model of Collective Resilience, a theory well-defined by social psychologists that shows that disasters can create a common identity through a sense of shared fate. Even though they are strangers to one another, bystanders involved in disaster events don’t panic and react wildly, but instead often act in orderly, cooperative and altruistic behavior to escape what is perceived as a common threat.1

Published anecdotes in the aftermath of a disaster that illustrate these facts are commonplace. For example, 21-year-old Stephanie Davies helped to save the life of her friend, 19-year-old Allie Young, who had been shot in the neck and upper chest in the early moments of the Century 16 movie theater shooting in Aurora in 2012. Despite the ongoing shooting and her critically injured friend imploring her to save herself, Davies stated in one interview that leaving her friend “was not an option.” Instead, she applied pressure on her friend’s bleeding neck wound, shielded her from additional injury, called 9-1-1, and then, assisted by another movie theatergoer, carried her injured friend “out of the theater and across two parking lots” to where ambulances were staged.2

There are multiple similar reports of citizens assisting the injured in the immediate aftermath of the 2013 Boston Marathon bombing, many using the resources immediately available to them such as windbreakers and T-shirts to comfort and provide treatment to the wounded.3,4

EMS leveraging bystanders as medical force multipliers during MCIs
Montville, Conn., police officer Karen Moorehead and Connecticut State Trooper Jeff Meninno—both off duty and having just arrived near the Boston Marathon finish line after watching the Red Sox game—come to the aid of bombing victim Jarrod Clowery. AP Photo/The Daily Free Press, Kenshin Okubo

Regarding actions by citizens in the aftermath of the 2005 bombings in London, Coroner Lady Justice Hallett was quoted as saying, “One of the most impressive things we’ve learnt is how fellow passengers went to see what they could do to answer those cries for help … and went into a war zone.”5

Examples of bystander response are not a recent phenomenon. As far back as the 1966 shooting at the tower on the campus of University of Texas in Austin, citizen bystanders were credited with saving the lives of some of those wounded by the shooter by pulling them out of harm’s way, often at great personal risk and subsequent injury.6

By examining recent cases of heroic bystander actions during and following unexpected disasters, we observe the following generalizations:

  • Some bystanders are active while others are passive;
  • Most bystanders have little or no first aid training. Even physicians and nurses unintentionally involved in the incident, unless specifically trained in field medicine, add little if any benefit;
  • Most bystanders respond to action without specialized equipment;
  • Bystanders come from any age, gender, race and ethnicity;
  • Bystanders aren’t so severely injured that they’re incapable of helping others;
  • Bystanders are there not by choice but by geography and circumstance;
  • Bystanders are the only potential rescue personnel present in the immediate aftermath. Even in the best circumstances, there will be time before public safety first response personnel will arrive; and
  • Bystanders are an important resource, especially given the size and numbers of wounded. There simply aren’t enough professional first responders to provide immediate care to all of the wounded.

To sum up the above generalizations: We know with confidence that bystanders will act and save lives.

Leveraging Resilience

Although several national organizations have recently made recommendations to empower civilian actions, these efforts and the subsequently recommended medical procedures have been limited in scope. For example, the Hartford Consensus report initially published in late 2012 has focused almost exclusively on external hemorrhage control, describing it as “the critical step” in eliminating preventable prehospital death.7 This recommendation is heavily based on the military combat wounding and fatality patterns and on the success of the military Tactical Combat Casualty Care (TCCC) training in reducing death from potentially survivable wounds on the battlefield.

The inherent assumption of using military combat data is that the wounding, fatality and population patterns in civilian active violence and mass casualty events are the same as that during combat operations. However, despite similar weapons often being used in civilian events, the combat pattern and subsequent specificities of the military medical response doesn’t directly translate to civilian events.

For example, data from recent active shooter incidents shows that the fatal wounding pattern from 139 victim autopsies revealed that only 7% of fatalities were from potentially preventable causes and that none of those deaths would have been prevented with a tourniquet. In fact, although there were recorded wounds to the extremities, there wasn’t a single incident of major vascular extremity hemorrhage that could be found among the dead.8

This differs greatly from the reported combat data where approximately 24% of fatalities are potentially preventable, 9% being extremity injuries that were potentially preventable with immediate and effective external hemorrhage control.9

EMS leveraging bystanders as medical force multipliers during MCIs
In addition to recognition and basic management on the preventable causes of death, such as external hemorrhage, First Care Provider training also emphasizes bystander safety and rapid evacuation to care. Photo courtesy FirstCareProvider.org

Do these data sets imply that tourniquets and external hemorrhage control efforts aren’t important for civilians? Absolutely not! External hemorrhage control actions are simple, effective and possibly lifesaving, and should absolutely continue to be emphasized as a part of a larger civilian bystander medical approach.

However, focusing broad bystander education and medical action to external hemorrhage alone will most likely not address the majority of potentially preventable deaths in civilian high-threat events. To truly empower bystanders to improve survivability and increase resilience, training must be across a spectrum of simple and effective medical techniques beyond bleeding control.

The civilian high-threat medical guidelines of Tactical Emergency Casualty Care (TECC) were created to address preventable deaths in civilian mass casualty and high-threat events through a civilian-focused, evidenced-based review of trauma guidelines, including the military TCCC guidelines, by the voluntary 501-3(c) non-profit Committee for Tactical Emergency Casualty Care (C-TECC).10

TECC is an evidence-based, expert consensus medical treatment model written by civilian first responders to account for the specifics of civilian operations and population. It has rapidly become the standard of care being applied by first responder agencies—both law enforcement and fire/EMS—for medical operations during high-threat scenarios.

The ideal implementation of TECC guidelines is in a systematic nature across all of the providers and agencies involved in unexpected disasters. This results in a TECC “chain of survival” that links the continuity of care across all potential medical providers from the bystander to the nonmedical law enforcement first responder to the medical EMS first responder to the trauma center first receiver. Each link in the chain has an appropriate scope-limited set of procedures that build upon one another and are carried forward as the patient moves up the chain. The first link in the TECC chain of survival is called “first care providers” (FCPs). They are, ideally, bystanders geographically involved by circumstance, who initiate care at or near the point-of-wounding.11

Bystander-Led Trauma Protocol

The FCP concept was created for those inevitable situations where wounded persons are actively dying from manageable injuries while professional first response medical care is unavailable due to deployment and/or operational limitations.11 It represents a universal bystander-led trauma protocol based on the appropriate scope of practice and logistical limitations of bystander care.

FCP training doesn’t focus solely on external bleeding control, but instead takes a more comprehensive approach to addressing all causes of preventable death. It differs dramatically from common civilian medical programs (e.g., first aid, CPR, etc.) and adheres to the TECC guidelines recommended by the C-TECC. The universality of the FCP model makes it an appropriate subject to be included as part of an ongoing safety program, new employee orientation or as a standalone course.11

The FCP model acknowledges that external hemorrhage control is a critical skill for all traumatic type injuries but also emphasizes bystander safety training, recognition of critical injury, the initial basic management of all of the preventable causes of traumatic death (e.g., bleeding, airway, chest injury and hypothermia) and rapid evacuation to care.

Beyond Public Access Tourniquets

A substantive community-based disaster resiliency program should be based on a foundation of three pillars: 1) administrative buy-in; 2) availability of equipment; and 3) comprehensive FCP training.11

Reluctance to change is perhaps the most critical barrier to overcome. Community and public safety leadership must overcome a complete reliance on traditional 9-1-1 response and a reluctance to introduce medical policy and empower medical action in the broader population.

The broad availability of tourniquets in civilian trauma response remains an admirable goal, but ongoing studies in California12 and anecdotal experience in Arlington County, Va., demonstrates that proper tourniquet application to complete arterial occlusion isn’t an obvious skill for the untrained person, but direct pressure and elastic wrap pressure dressings appear to be. This is likely due to familiarity with ACE-type elastic bandages and the simplicity of direct pressure along with the well-documented fear of causing further injury that can limit bystander action.13

Public-access hemorrhage control and mass casualty kit inventory shouldn’t exclusively contain tourniquets; consideration should be given to including other items such as pressure bandages, chest seals and blankets as well.

Public-access medical equipment should be part of a multipronged approach to community safety. It not only provides critical equipment on scene at the time of an event, but also can serve as a visual cue to action for those involved. Mounting and displaying the available equipment can maximize visualization and recognition. Signage indicating the location of equipment should mirror efforts currently undertaken for fire extinguishers, AEDs and emergency exit planning.

Additionally, purchasing lifesaving medical equipment without either reference to civilian medical recommendations nor in combination with a civilian-focused educational model is ineffective.

Civilian training programs can impart the simple knowledge needed to utilize manufactured and improvised tourniquets effectively. As recent research conducted by the nonprofit group www.firstcareprovider.org and the Westminster (Calif.) Police Department demonstrates, the bystander response significantly improves after basic familiarization training around the skills and equipment.12

Once trained, FCPs demonstrated a willingness to operate independently, recognize critical injuries and properly allocate resources for maximal benefit of those involved.12

Public-access medical equipment combined with FCP training empowers individuals to take action in times of crisis and will encourage individuals to work independently and without public safety first responder supervision.

Conclusion

It’s critical to recognize the gap left by current disaster planning assumptions and existing medical curricula as it relates to the involved yet uninjured bystander. Although external hemorrhage control education and equipment access may be the most attainable goal for some communities, limiting training and focus to just this cause of death runs the risk of falsely elevating community belief that simply putting hemorrhage control equipment in public places will be a panacea to end the deaths in targeted violence events.

Because excellent and efficient medical response services are readily available during normal times, society harbors unrealistic expectations of both the availability and capacity of our medical response system in times of complex, dynamic crises. This leads to a perception gap between what our public expects vs. the actual capacity of the EMS system.

Assumption that any public safety system will be able to easily absorb the additional demands required by disaster scenarios and provide the rapid medical response to the patient’s side as occurs during normal operations is simply unrealistic. The uninjured bystander acting as an FCP can be an effective way to bridge the delay in professional medical first response. FCPs represent the first link in the high-threat and targeted violence chain of survival and are a readily available but currently underutilized source of medical force multiplication.

A concerted community-based effort to bring the totality of appropriate medical care, not just hemorrhage control, to potentially survivable victims will have the greatest chance of improving survivability and increasing resilience to these events.

References

1. Drury J, Cocking C, Reicher S. The nature of collective resilience: Survivor reactions to the 2005 London bombings. International Journal of Mass Emergencies and Disasters. 2009:27(1);66–95.

2. Stump S. (Aug. 15, 2012.) Woman in Aurora shooting: Leaving injured friend ‘wasn’t an option.’ TODAY.com. Retrieved June 25, 2016, from www.today.com/id/48673495/ns/today-today_news/t/woman-aurora-shooting-leaving-injured-friend-wasnt-option.

3. Ng C. (April 16, 2013.) Boston marathon bystanders raced to the rescue. ABC News. Retrieved July 7, 2016, from http://abcnews.go.com/US/boston-marathon-bystanders- raced-rescue/story?id=18966272.

4. Bowerman M. (April 15, 2016.) Boston Marathon bombing survivors and first responders: Where are they now? USA TODAY. Retrieved July 7, 2016, from http://www.usatoday.com/story/news/nation-now/2016/04/14/boston-marathon-bombing-survivors-and-first-responders-where-they-now/83026086/.

5. BBC News. (Nov. 18, 2010.) 7/7 victims ‘might have been saved.’ Retrieved June 25, 2016, from www.bbc.com/news/uk-11776933.

6. Bowden C. (Jan. 29, 2007.) The Tower tragedy. Esquire. Retrieved June 25, 2016, from www.esquire.com/news-politics/a1697/esq0299-feb-america-rev.

7. Jacobs LM, McSwain NE Jr, Rotondo MF, et al. Improving survival from active shooter events: The Hartford Consensus. J Trauma Acute Care Surg. 2013;74(6):1399–1400.

8. Smith ER, Shapiro G, Sarani B. The profile of wounding in civilian public mass shooting fatalities. J Trauma Acute Care Surg. 2016;81(1):86–92.

9. Eastridge BJ, Mabry RL, Seguin P. Death on the battlefield (2001-2011): Implications for the future of combat casualty care. J Trauma Acute Care Surg. 2012;73(6 Suppl 5):S431–S437.

10. Callaway DW, Smith ER, Cain J, et al. Tactical emergency casualty care (TECC): Guidelines for the provision of prehospital trauma care in high threat environments. J Spec Oper Med. 2011;11(3):104–122.

11. Callaway D, Bobko J, Smith ER, et al. Building community resilience to dynamic mass casualty incidents: A multiagency white paper in support of the first care provider. J Trauma Acute Care Surg. 2016;80(4):665–669.

12. Bobko JP, Kamin R. Changing the paradigm of emergency response: The need for first-care providers. J Bus Contin Emer Plan. 2015;9(1):18–24.

13. Swor R, Khan I, Domeier R, et al. CPR training and CPR performance: Do CPR-trained bystanders perform CPR? Acad Emerg Med. 2006;13(6):596–601.


For more information on First Care Provider training, go to www.C-TECC.org and www.firstcareprovider.org.