Special Focus on Active Shooter Incidents & Tactical Emergency Casualty Care

High-profile and high-fatality events have put substantial pressure on public safety agencies to respond and mitigate threats rapidly, quickly treating injured responders and victims as close to their point of injury as possible.

Following the Sandy Hook Elementary School active shooter incident (ASI) in Newtown, Conn., the American College of Surgeons and the FBI collaborated to respond to the ongoing threat of ASIs by assembling specialists in surgery and emergency medicine. Their goal was to quickly identify a plan of action to increase victim survival using concepts and actions supported by the medical literature and by military and civilian operational experience.

The group met in Hartford, Conn. Thus, the product of this important effort is called “the Hartford Consensus.”

With solid evidence from the military on the effectiveness of rapid care at the point of conflict, and new techniques and products to rapidly stem active bleeding in combat situations, the Hartford Consensus calls for a coordinated response by law enforcement, rescue and EMS, and receiving hospitals with the goal of controlling hemorrhage as quickly as possible.
Similar to the approach used by the Hartford Consensus, PennWell, publisher of the Journal of Emergency Medical Services (JEMS), Law Officer, Fire Engineering, FireRescue Magazine and Public Safety Communications, convened experts in the field of ASI medicine and tactical emergency casualty care (TECC) to focus on the need for, and delivery of, rapid care for officers, crews and patients involved in incidents that have a high probability for injuries and fatalities so that we, as a response community, can reduce morbidity and mortality.

This special editorial supplement presents not just the results and recommendations of the Hartford Consensus, but also the latest data and techniques on how to care for yourself, your co-workers and victims of violent and fast-moving incidents.

To exhibit why this is so important, I want to point out some key facts presented in research of ASIs from 2000 to 2012 conducted by Texas State University through examination and cross-referencing of police reports, public records and media reports. This data serves as a blueprint for why we must focus on early and rapid emergency care in the field:1

  • The frequency of events is increasing, from approximately one every other month between 2000 and 2008 (five per year) to more than one per month between 2009 and 2012 (almost 16 per year). In 2013, 72 people were shot and 39 were killed in an ASI.
  • Schools were the second-most attacked locations (29%), and approximately 20% occurred in outdoor environments. Responders must be trained to operate in both outdoor and indoor (i.e., close quarters) environments, recognizing the tactics for each are different.
  • The median number of people shot per event was five, exhibiting why multiple tourniquets and hemorrhage control supplies must be available early at all ASIs. One tourniquet per ambulance will be inadequate. Recommendations are that all responders carry tourniquets, learn to “pack” wounds and have hemostatic (wound-clotting) bandages and dressings as well as dressings that can seal open chest wounds.
  • Shooters brought multiple weapons in 33% of the attacks. In 3% of the cases, perpetrators brought IEDs to the attack site and wore body armor 5% of the time.
  • In 51% of the cases, the ASIs were still ongoing when law enforcement arrived. Of these, attackers stopped themselves when police arrived 40% of the time, most commonly by committing suicide.
  • In 7% of the cases, the attacker shot the responding officers. If you look at the 53 shootings that were “active” at the time police arrived, officers were shot in 15% of events. That makes ASIs among the most dangerous in law enforcement.
  • In 18 events, solo officers arrived and engaged the shooter; 72% were still ongoing when solo officers arrived on scene. However, in solo incidents officers were more likely to be injured during these events, with 17% of officers shot.

Make no mistake about it, active shooter events are dangerous and challenging for all emergency responders and require a systematic search of the attack location to mitigate the threat, find and treat victims and confirm there’s not another shooter. In a large attack site, this search can take hours. During this time, victims may bleed to death or die from shock.

We must train and equip law enforcement officers to provide care at the points of impact. Many areas are incorporating the rescue task force concept and including EMS personnel in entry teams to stabilize and rapidly remove the injured while a ballistic or explosive threat may still exist.

Read this supplement and then work with all the agencies that will be on the scene of ASIs and other incidents requiring TECC so that you’re prepared to protect and perhaps save yourself while saving others at these fast-moving, high-risk events.

1. Blair JP, Martaindale MH, Nichols T. (Jan. 7, 2014.) Active shooter events from 2000 to 2012. FBI Law Enforcement Bulletin. Retrieved July 31, 2014, from http://leb.fbi.gov/2014/january.


  • A.J. Heightman, MPA, EMT-P, is editor emeritus of JEMS and an adjunct instructor of Clinical Research and Leadership with the George Washington University School of Medicine and Health Sciences.

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