EMS actions must not degrade the police response or place either EMS or the police at increased risk by complicating the tactical situation. Photo courtesy FBI
An active shooter is an individual actively engaged in killing or attempting to kill people in a confined and populated area.1 Recent active shooter incidents have underscored the need for a coordinated response by public safety agencies to save lives.
As we approach the second anniversary of the Sandy Hook Elementary School shooting, which resulted in the murder of 27 children and adults in Newtown, Conn., it’s sensible to take stock of the lessons learned and actions taken by public safety agencies as a result of that extraordinary tragedy.
A Challenge to Every Community
Mass casualty shooting incidents aren’t new in the United States. The 1966 “Tower Sniper” incident at the University of Texas, Austin, left 14 dead and 31 injured at the hands of a single gunman.2 The 1999 Columbine, Colo., incident was perpetrated by two assailants who killed 13 and wounded 24.3
Since Columbine, active shooter incidents have become more frequent. In the eight-year period after Columbine, an average of five active shooter events occurred per year. Since 2009, that figure has increased threefold.4
While the reason for this increase is unclear, the layperson’s impression that active shooter incidents have become more frequent appears valid. A recent study by Texas State University (TSU) examined and cross-referenced police reports, public records and media reports for the period 2000–2012.5 The increased frequency of incidents seen in the TSU study isn’t explained by changes in case definition or solely on the basis of increased case reporting.
The FBI is actively collecting and analyzing detailed data on these incidents. This ongoing effort is a source of periodic guidance to improve actions to prevent, prepare for and respond to active shooter mass casualty incidents (MCIs).
The TSU study also observed that most active shooter incidents (40%) occurred in places of business including offices, stores and industrial locations. Schools and colleges were the next most common locations for these events at 29%. The assailant moved between multiple locations in almost 20% of the incidents and had no apparent connection to the shooting location almost 50% of the time.
These findings emphasize the need for all communities to develop response plans for an active shooter event. These incidents have occurred in municipalities of all sizes, raising the possibility of similar MCIs occurring without warning in communities with limited police, rescue and emergency medical resources.
From the standpoint of definitive care, another significant finding of the TSU analysis is that the median number of shooting victims was five per incident. This translates to 58 incidents over a 12-year period in which at least five victims were shot. In preparing for active shooter incidents, hospital emergency and surgical departments must address the major challenge of providing timely treatment to multiple victims of gunshot wounds to the chest and abdomen.
So, almost two years after Sandy Hook, what has been accomplished?
The Hartford Consensus
In the period following Sandy Hook, the American College of Surgeons (ACS) and the FBI collaborated to respond to the ongoing threat of active shooter events by assembling a group of surgery and emergency medicine specialists. The goal was to quickly identify a plan of action to increase survival of victims of these events, using concepts and actions supported by the medical literature and by operational experience.
These recommendations were developed and presented as apolitical and achievable within the existing budgets of communities of any size. The product of this effort is the Hartford Consensus.6
The bottom-line imperative of the Hartford Consensus is that “no one should die from uncontrolled bleeding.” Citing evidence of the effectiveness of actions taken in military medicine over the past decade, the Consensus calls for a coordinated response by law enforcement, fire/rescue, EMS and receiving hospitals with the goal of controlling hemorrhage as quickly as possible.
While victims who receive immediately lethal wounds can’t be saved, as was the unfortunate case in Sandy Hook, rapid control of hemorrhage in victims of otherwise survivable wounds will have the greatest impact in total lives saved.
An acronym describing the required actions by responders at all levels is THREAT. (See Figure 1.) Each THREAT step is critical to victim survival in fast-moving active shooter or MCI incidents. These steps are: Hemorrhage control, either by prevention of further injuries or by rapid recognition and control of the subset of life-threatening hemorrhage treatable on scene; extraction and triage of victims with internal hemorrhage for prioritized transport; and definitive surgical treatment at a hospital for those victims with internal hemorrhage.
Figure 1: THREAT acronym
By the time of its second meeting in July 2013, the Hartford Consensus group had expanded to include representatives of law enforcement, emergency, surgical and military medicine, fire/rescue and EMS as well as representatives of the Federal Emergency Management Agency and the White House National Security Staff.
This larger group focused on how their organizations could assist their colleagues in the field in implementing the THREAT concept in their communities. Another goal was to identify educational tools and performance measures to ensure that programs to reduce death and injury in active shooter/MCIs were sustainable and their effectiveness validated.
Intended to develop broadly acceptable concepts for countermeasures to the active shooter problem, the Hartford group worked for weeks, hoping to harness the motivation for action that followed the Sandy Hook tragedy. At the same time, the ACS, FBI and others pursued parallel projects over a longer term.
Benchmarks of Progress since Sandy Hook
Since Sandy Hook, a number of national public safety organizations have advocated for improved response to active shooter and intentional MCIs, incorporating the basic concepts of the Hartford Consensus in their recommendations.
In September 2013, following collaboration with leaders of public safety agencies and professional organizations, the U.S. Fire Administration (USFA/FEMA) released detailed operational guidance for fire and EMS agencies in development of local active shooter response plans.
Following the Boston Marathon bombing the previous April, this project expanded its scope to include similar contingencies. The resulting manual assists local agencies in using existing incident command and control concepts in the context of active shooter and MCI events.7
In addition to the efforts of USFA/FEMA and participation in the discussions previously mentioned, the Department of Homeland Security (DHS) brought together authorities in medicine, law enforcement, fire/rescue and EMS at all levels with specialists in the private and public sectors to develop collaborative guidance for active shooter and MCI planning.
In February 2014, the DHS Office of Health Affairs assembled over 250 representatives to continue this process, working collaboratively on specifics of hemorrhage control, protective equipment, interoperability of responding authorities and advocating for a role for citizen bystanders in MCIs.8 Recommendations in these important areas of concern are expected in the near future.
As part of President Barack Obama’s directive to expand access to federal active shooter training, the Department of Justice (DOJ) launched its active shooter response training initiative.9–11 A central component of the initiative is Advanced Law Enforcement Rapid Response Training (ALERRT), a program partnership between Texas State University, the San Marcos (Texas) Police Department and Hays County (Texas) Sheriff’s Office.
ALERRT and the DOJ have been associated for more than a decade. In June 2013, the FBI established ALERRT as the recommended national standard for active shooter response training.12
ALERRT includes training in emergency hemorrhage control and recognizes this skill as a law enforcement function. This training has been provided at no cost to over 50,000 police officers. With additional DOJ support under the active shooter initiative, an additional 30,000 officers are to receive training in the next 18 months.13
Beginning in March 2013, the FBI’s 56 field offices hosted active shooter workshops for more than 10,000 police commanders from approximately 4,400 agencies. More than 7,600 leaders from more than 3,000 public safety agencies at all levels of government have attended tabletop exercises in active shooter response and recovery since that time. And, in an internal effort, the FBI expanded medical first aid training emphasizing immediate hemorrhage control to all of its 12,000 special agents.13
Progress on the Street
Since the beginning of 2013, more than 30 police departments across the country, varying in size and available resources, have provided local training in emergency hemorrhage control to approximately 82,000 law enforcement officers.14 Encouraged by organizations like the Major Cities Chiefs Association and others, these efforts complement federally sponsored law enforcement medical training.
These programs can be incorporated into existing plans and budgets, and when supported by the agency medical authority, can serve as a bridge to their colleagues planning active shooter response in the fire/rescue and EMS communities and at destination hospitals.
The national EMS community is more diverse than law enforcement, making integration of EMS into active shooter response a complex task. While inclusion of hemorrhage control in police doctrine can gain ready acceptance as an officer safety issue, bringing EMS closer in time and space to an active shooter scene is a more difficult concept to implement.
In the minority of communities where the police provide EMS services, rapid suppression of the threat can be followed by entry of medically-trained law enforcement officers performing the rapid extrication and first medical assessment of victims.
In the majority of communities where EMS isn’t a police service function, public safety officials must develop a response plan that’s workable within the resources and risk tolerance of that community.
A number of national organizations, including the International Association of Fire Chiefs and the International Association of Fire Fighters have encouraged the Rescue Task Force (RTF) concept.15,16 RTFs are a means of providing faster medical access to an active shooter scene, after elimination or isolation of the shooter threat, before completion of the laborious process of fully clearing the location of possible hidden threats.
While this approach is unlikely to become universal, a number of communities have developed joint RTFs, and have conducted critically important field training exercises to implement and fine tune the complex process of rapid access, reassessment and evacuation of victims triaged in order of severity. (Editor’s note: For more on RTFs, see “Inside the Warm Zone: Blacksburg Volunteer Rescue Squad partners with police to create a rescue task force” in May JEMS.)
During the 2013 Boston Marathon bombing, rapid control of hemorrhage in victims of otherwise survivable wounds was critical to saving lives. AP Photo/Kenshin Okubo
The Continuing Challenge
A number of recurring concepts were noted by the group at the first and second meetings of the Hartford Consensus. First, because the next active shooter event can occur anywhere in the U.S., local public safety in all communities must incorporate active shooter planning into their operations. The ability to respond immediately and effectively is critical if the number of victims and loss of life are to be minimized. This means all elements of a coordinated public safety response to an active shooter must be available at all times, on every shift, and integrated into the routine operations of fire/rescue and EMS services as well as the police.
Regular training and review by leaders across public safety agencies are required to ensure a practiced, coordinated response by police, fire/rescue services and EMS without advance notice. We must remain capable of deploying special teams to critical incidents, as the possibility of complex attacks involving multiple assailants and unconventional threats certainly exists. However, experience over the past decade and a half demonstrates that the vast majority of incidents involve one assailant armed with conventional firearms.11
This is partly the basis of the change in police tactics advocating immediate engagement of the shooter by patrol officers. Like law enforcement, fire/rescue and EMS agencies must be capable of rapid action without the delay required to marshal special operations teams.
Second, hemorrhage control actions by the police must be taught and applied in a manner consistent with law enforcement tactics. These skills must augment rather than degrade the primary police mission of stopping the wounding of additional victims while managing the risk to responding officers, who are at statistically high risk for injury as they engage the shooter.5
The same requirement applies to supporting actions by fire/rescue and EMS. Their actions must not degrade the police response or place themselves or the police at increased risk by complicating the tactical situation any more than necessary.
Coordinated active shooter responses by police, fire/rescue and EMS are complex, and don’t lend themselves to a cookie cutter approach. To be effective they must be tailored to the resources and level of risk tolerance of a given community.
Third, if community-based active shooter plans are to become a long-term capability, education and training in the skills and concepts underlying these plans must be provided consistently over the long term.
Existing training programs such as the Prehospital Trauma Life Support (PHTLS) course and the military equivalent Tactical Combat Casualty Care (TCCC) course are examples of medical analogs to the special training available to our law enforcement colleagues. The recent ACS guideline for prehospital hemorrhage control is an example of the evidence-based guidance needed to improve the uniform effectiveness of emergency care prior to arrival at the hospital.17
Development of similar training and guidance applicable to critical incidents is one means of maintaining an effective, agile medical response to active shooter and other criminal MCIs.
Finally, it’s important that access to surgical care is in place at the end of the continuum of public safety response to active shooter events. While appropriate emphasis is placed on field tourniquet control of extremity hemorrhage, victims of penetrating chest and abdominal wounds require priority triage and evacuation to a surgical suite. In parts of the country with limited hospital resources, surgeons and their emergency medicine colleagues will play an important role by ensuring that the hospital contingency plans required for accreditation include the capability to provide damage control surgery to multiple victims of an active shooter event.
While trauma center designation isn’t an option for some smaller hospitals, a basic emergency surgical capability for all hospitals similar to that in place in hospitals in Israel is a concept worth consideration in areas with limited services.18,19
Emergency hemorrhage control techniques employed in the field, such as a pressure dressing, hemostatic dressing or a tourniquet require definitive treatment at the ED or in the surgical suite. Penetrating wounds to the chest or abdomen require the services of the surgeon.
It falls upon emergency physicians to maintain familiarity with current recommendations for hemorrhage control and initial hospital trauma treatment. And, like their emergency medicine colleagues, general surgeons who don’t treat penetrating trauma frequently may benefit from continuing education and training in this area offered by ACS and other institutions.20,21
Maintaining basic trauma receiving capability at all potential receiving hospitals is a critical part of active shooter and mass casualty response. The role of the receiving hospital is deserving of increased recognition.
Training applicable to critical incidents is one means of maintaining an effective, agile medical response to active shooter/MCIs. Photo courtesy FBI
Seeing the Whole Picture
Professionals in public safety, prehospital and hospital-based medical care might also ask, “Two years later, what do we do next?”
As all segments of our community continue robust efforts to prepare for and respond to active shooter events and incidents like the Boston Marathon bombing, we would be well served to find ways to measure the effectiveness of these efforts.
The professions of law enforcement, EMS and hospital care are resource intensive, and both monetary and human resources are limited. The validity and effectiveness of the countermeasures we propose can only be proven if we collect data. The U.S. military improved the survival of its wounded members by changing their approach to life-threatening hemorrhage across the spectrum of care from field medic and casualty evacuation to trauma surgeon and combat support hospital.22
Change of this magnitude was made in large part because our medical colleagues in the Defense Department masterfully collected and interpreted patient data to develop an evidence-based reason for change.
Our civilian medical care system doesn’t lend itself to easy collection of data on patient outcomes. Patients move through the care continuum from first responder to EMS to the various departments of one or more hospitals, each modality with different ownership, supervision and data management. Important legal protections to personal medical information have the unfortunate side effect of impeding collection of data, either by law or by misinterpretation.
The majority of medical evidence supporting our current effort to improve survival from these events is derived from the military. While anecdotal reports of survival of wounded police officers and civilian victims is highly motivating and a source of encouragement, methods to collect treatment and outcome data on victims of these events are needed.
Detailed injury and treatment information is required at each phase of the emergency care continuum in order to know which techniques, procedures and equipment provide the best chance for survival. This process is critically important to making informed decisions on where to devote finite human and financial resources. The need for data supporting evidence-based trauma treatment is well recognized in the medical community. Incorporating data on the use of tourniquets, hemostatic agents and junctional hemorrhage control devices within trauma registries and similar databases will significantly enhance the ability to evaluate and improve what we do.
It’s important that data from all points in the patient care continuum be included, in a manner preserving medical confidentiality and in compliance with the law, while presenting a complete picture of the progression of patient care in statistically useful ways.
Considerable progress has been made since the tragic events at Sandy Hook prompted an increased focus on response to active shooter events in the U.S. It’s critical to recognize that the most important response to these incidents is local, and that continued support of local public safety agencies in all parts of the country is key to improving survival for victims of these tragic events.
1. Active shooter/mass casualty incidents. (n.d.) Federal Bureau of Investigation. Retrieved July 1, 2014, from www.fbi.gov/about-us/cirg/active-shooter-and-mass-casualty-incidents.
2. McDowall K. (Aug. 1, 2012.) Remembering the UT tower shooting 46 years later. Alcalde. Retrieved July 1, 2014, from http://alcalde.texasexes.org/2012/08/remembering-the-ut-tower-shooting-46-years-later.
3. Victims of the Columbine High School shooting. (n.d.) A Columbine Site. Retrieved July 1, 2014, from www.acolumbinesite.com/victim/injured.html.
4. Attorney General Eric Holder delivers remarks at the International Association of Chiefs of Police annual conference. (Oct. 21, 2013.) U.S. Department of Justice. Retrieved July 1, 2014, from www.justice.gov/iso/opa/ag/speeches/2013/ag-speech-131021.html.
5. Blair JP, Martaindale MH, Nichols T. (Jan. 7, 2014.) Active shooter events from 2000 to 2012. FBI Law Enforcement Bulletin. Retrieved July 1, 2014, from http://leb.fbi.gov/2014/january.
6. Jacobs LM, Wade DS, McSwain NE, et al. The Hartford Consensus: THREAT, a medical disaster preparedness concept. J Am Coll Surg. 2013;217(5):947–953.
7. Fire/emergency medical services department operational considerations and guide for active shooter and mass casualty incidents. (September 2013.) U.S. Fire Administration. Retrieved July 1, 2014, from www.usfa.fema.gov/downloads/pdf/publications/active_shooter_guide.pdf.
8. Department of Homeland Security Office of Health Affairs. (May 16, 2014.) Event summary: Stakeholder engagement on improving survivability in IED and active shooter events. NAEMT. Retrieved July 1, 2014, from www.naemt.org/Files/LEFRTCC/Improving%20Survivability%20in%20IED%20and%20Active%20Shooter%20Incidents.pdf.
9. Training first responders and school officials on active shooter situations. (n.d.) The White House. Retrieved July 1, 2014, from www.whitehouse.gov/sites/default/files/docs/fact_sheet_training_first_responders_and_schools_on_active_shooter_situations.pdf.
10. Active shooter response training. (Oct. 31, 2013.) United States Department of Justice. Retrieved July 1, 2014, from www.bja.gov/ProgramDetails.aspx?Program_ID=106.
11. Schweit KW. (May 7, 2013.) Addressing the problem of the active shooter. FBI Law Enforcement Bulletin. Retrieved July 1, 2014, from www.fbi.gov/stats-services/publications/law-enforcement-bulletin/2013/May/active-shooter.
12. Bureau of Justice Assistance’s active shooter response training initiative. (n.d.) ALERRT Texas State. Retrieved July 1, 2014, from www.alerrt.org/StaticPages/view/31.
13. FBI Active Shooter Initiative. (n.d.) Email interview.
14. Eastman AL. (n.d.) Email interview.
15. Active shooter and mass casualty events position statement. (Oct. 10, 2013.) International Association of Fire Chiefs. Retrieved July 1, 2014, from www.iafc.org/files/1ASSOC/IAFCPosition_ActiveShooterEvents.pdf.
16. IAFF position statement: Active shooter events. (n.d.) International Association of Fire Fighters. Retrieved July 1, 2014, from www.iaff.org/Comm/PDFs/IAFF_Active_Shooter_Position_Statement.pdf.
17. Bulger EM, Snyder D, Schoelles K, et al. An evidence-based prehospital guideline for external hemorrhage control: American College of Surgeons Committee on Trauma. Prehosp Emerg Care. 2014;18(2):163–173.
18. Einav S, Feigenberg Z, Weissman C, et al. Evacuation priorities in mass casualty terror-related events: Implications for contingency planning. Ann Surg. 2004;239(3):304–310.
19. Frykberg ER. Principles of mass casualty management following terrorist disasters. Ann Surg. 2004;239(3):319–321.
20. Advanced trauma life support. (n.d.) American College of Surgeons Trauma Programs. Retrieved July 1, 2014 from www.facs.org/trauma/index.html.
21. Advanced trauma operative management. (n.d.) American College of Surgeons Trauma Programs. Retrieved July 1, 2014, from www.facs.org/trauma/atom/.
22. Kotwal RS, Montgomery HR, Kotwal BM, et al. Eliminating preventable death on the battlefield. Arch Surg. 2011;146(12):1350–1358.