World J Surg (2014) 38:1007–1008 DOI 10.1007/s00268-014-2481-7

ORIGINAL SCIENTIFIC REPORTS

The Hartford Consensus: How to Maximize Survivability in Active Shooter and Intentional Mass Casualty Events Lenworth Jacobs

Published online: 11 March 2014 Ó Socie´te´ Internationale de Chirurgie 2014

The recent events at the Boston Marathon bombings, the bombing at the shopping mall in Nairobi, Kenya, and the shootings at the Navy Yard in Washington, DC continue to make it clear that active shooter and intentional mass casualty incidents require comprehensive responses to increase survival and minimize disabilities. The Joint Committee to Create a National Policy to Enhance Survivability from Mass Casualty Shooting Events was formed to identify the needed changes to improve survival. It was initiated by the American College of Surgeons (ACS) in an effort to ensure that victims receive expeditious treatment of their injuries. On 2 April and 11 July 2013, a group of select representatives from national public safety organizations that included health, law enforcement, fire, prehospital care, trauma care, and the military met in Hartford, Connecticut, USA to suggest strategies to increase survivability from active shooter and intentional mass casualty events. The concepts supported by both meetings have become known as the Hartford Consensus [1, 2]. The overarching principle of the Hartford Consensus is that the current response and management of these events needs to change. Lessons learned from previous events make this clear. An analysis of the emergency medical response at Columbine High School in Colorado revealed that there was significant delay and some victims may have died waiting for medical treatment [3]. More recently, at the Los Angeles Airport shooting on 1 November 2013, an officer was wounded and left unattended for 33 min even though for most of that time there was no threat from the suspected gunman [4]. The officer had no signs of life upon

L. Jacobs (&) Academic Affairs, Hartford Hospital, Hartford, CT, USA e-mail: [email protected]

arrival at the medical center and was unable to be revived. Delays such as these are not acceptable. There are several reasons for the delay in attending to victims. The response to events is hindered by the lack of a unified command structure and common language of the various responding groups. Because these events typically happen in a very short time, any delay in formulating a coordinated response can mean the difference between life or death for the victims. Traditionally, responding police officers have focused on suppressing the shooter. Until that is accomplished, treating victims is a secondary objective. Providing hemorrhage control has not been one of their responsibilities. The desire to provide a safe environment for emergency medical services (EMS) has prevented access to victims until law enforcement grants them access. This philosophy has resulted in medical responders waiting at the perimeter of the event. Law enforcement in the past has focused on management of the crime scene and collecting and preserving evidence to the detriment of victim survival. The Hartford Consensus has declared that these response issues must be eliminated and the expeditious attention to victim survival is a priority. The Hartford Consensus produced two documents [1, 2]. The first describes the fundamental concepts to increase survival and the second is a call to action. The call to action is that no one should die from uncontrolled bleeding. An acronym summarizes the needed response: THREAT (T indicates threat suppression, H for hemorrhage control, RE for rapid extrication of the victims from the scene, A for assessment by medical providers, and T for transport to definitive care). Although responders may include the public, law enforcement, EMS/fire/rescue, and definitive trauma care, hemorrhage control must be seen as a core law enforcement responsibility.

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The Hartford Consensus has recognized the public as potential first responders. As demonstrated at the Boston Marathon bombings, the uninjured or minimally injured public will act as nonprofessional first responders [5]. Bystanders in Boston played a critical role in the response by immediately delivering direct aid and comfort. These bystanders helped medical personnel place tourniquets, apply pressure to wounds, and transport victims to medical facilities [6]. They demonstrated that people spontaneously help each other. It is now time to formally recognize the general public as a source of aid in active shooter and intentional mass casualty incidents. It is time to capitalize on the human desire of citizens to help their fellow citizens in times of suffering and crisis. Communities everywhere should include the bystander-as-responder concept into their planning, preparation, and training for active shooter and intentional mass casualty incidents [7]. There is a long history of bystander aid and training in this country. Perhaps the most noted and widespread public education in rendering of aid has been through the efforts of the American Red Cross and the American Heart Association in cardiopulmonary resuscitation (CPR) and the use of automatic external defibrillators (AEDs). Indeed, there are now AEDs in most public places, and cities and towns proudly display that they are heart safe communities. Similarly, training in the Heimlich maneuver is also extensively offered and many lives have been saved from choking because a member of the public was educated in performing this technique. It is time to teach the public how to render assistance in active shooter and intentional mass casualty incidents. Along with education, appropriate supplies to control bleeding must be readily available. Every police officer should carry a tourniquet. Tourniquets should be readily available in all public places. Just as AEDs are available and recognizable, so should tourniquets and hemostatic dressings. Some members of the public might accept having these life-saving materials readily available to them personally. The military and hunting enthusiasts already appreciate this. It is incumbent that fully integrated responses be available at any time of day or night in any geographic

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location regardless of the size and sophistication of the response teams. Education and coordination of all responders—police, EMS/fire/rescue, and the public— needs to be widely implemented. The intention of the Hartford Consensus is that preventable death from an active shooter or an intentional mass casualty event is eliminated through the use of a unified, seamless, and integrated response system that comprehensively implements the THREAT actions [8].

References 1. Jacobs LM, McSwain N, Rotondo M, Wade DS, Fabbri WP, Eastman A, Butler FK, Sinclair J, Joint Committee to Create a National Policy to Enhance Survivability from Mass Casualty Shooting Events (2013) Improving survival from active shooter events: the Hartford Consensus. Bull Am Coll Surg 98(6):14–16 2. Joint Committee to Create a National Policy to Enhance Survivability from Mass Casualty Shooting Events, Jacobs LM, Rotondo M, McSwain N, Wade DS, Fabbri WP, Eastman A, Butler FK, Sinclair J, Burns K, Brinsfield K, Carmona R, Serino R, Conn A, Kamin R (2013) Active shooter and intentional mass casualty events: the Hartford Consensus II. Bull Am Coll Surg 98(9):18–22 3. Gotthelf M (2014) Police response a matter of debate. Some still question whether cops did all they could do. http://www. operationaltactics.org/media/Columbine%20article.pdf. Accessed 19 Feb 2014 4. Abdollah T (2014) LAX shooting: TSA officer Hernandez bled for 33 minutes at scene-report. http://usnews.nbcnews.com/_news/ 2013/11/15/21471203-lax-shooting-tsa-officer-hernandez-bled-for33-minutes-at-scene-report?lite. Accessed 19 Feb 2014 5. Walls RM, Zinner MJ (2013) The Boston marathon response, why did it work so well? JAMA 309(23):2441–2442 6. Leonard HB, Howitt AM (2014) Preliminary thoughts and observations on the Boston Marathon bombings. http://www.hks. harvard.edu/var/ezp_site/storage/fckedit/file/pdfs/centers-programs/ programs/crisis-leadership/Leonard/%20and%20Howitt_Boston% 20Marathon_Preliminary%20Thoughts%20HBL%20AMH%2020 13%2004%2022%20v3.pdf. Accessed 19 Feb 2014 7. Lord G (2014). Bystanders who didn’t stand by. http://www. demingheadlight.com/ci_23280658/bystanders-who-didnt-standby#. Accessed 19 Feb 2014 8. Jacobs LM, Wade DS, McSwain NE, Butler FK, Fabbri WP, Eastman AL, Rotondo M, Sinclair J, Burns KJ (2013) The Hartford Consensus: THREAT, a medical disaster preparedness concept. J Am Coll Surg 217(5):947–953