Opinion
VIEWPOINT
Lenworth M. Jacobs, MD, MPH Academic Affairs, Hartford Hospital, Hartford, Connecticut; and Traumatology and Emergency Medicine, University of Connecticut, Storrs. Karyl J. Burns, RN, PhD Academic Affairs, Hartford Hospital, Hartford, Connecticut.
Corresponding Author: Lenworth M. Jacobs, MD, MPH, Hartford Hospital, Academic Affairs, 80 Seymour St, Hartford, CT 06102 (lenworth.jacobs @hhchealth.org).
Improving Survival From Intentional Mass Casualty Incidents The Need for a National Curriculum With mass shootings happening more frequently, the epidemic of gun violence in the United States continues to produce death and suffering. 1,2 This is true even though considerable attention has been directed at mental health services and gun control. While gun violence and mass killings will continue to occur, steps can be taken to improve survivability. One area on which to focus is the prompt assessment and treatment of victims. Improved survivability requires changes in how law enforcement and all potential first responders, including the public, respond. As demonstrated at the Boston Marathon bombings, the public can, and will, act as first responders.3 While considerable effort will be needed to implement changes, change in this realm seems more likely to have a more expeditious and widespread effect. A national curriculum to improve the first actions of professional and lay responders is needed. Shortly after the killings at Sandy Hook Elementary School, in the spring of 2013, the American College of Surgeons commissioned the creation of The Joint Committee to Create a National Policy to Enhance Survivability From Mass Casualty Shooting Events. The committee held 2 meetings in the spring and fall of 2013 in Hartford, Connecticut. Within weeks of the first Hartford Consensus meeting, the bombings at the Boston Marathon took place. This led to the expansion of the committee’s focus on shooting events to include all intentional mass casualty incidents. The findings of these meetings became known as the Hartford Consensus. The overarching principle of The Hartford Consensus is that no one should die from uncontrolled hemorrhage.4,5 The Hartford Consensus uses an acronym THREAT to succinctly describe the major determinants for improving survivability from intentional mass casualty events.4,5 T stands for threat suppression and indicates that the perpetrator must be stopped as soon as possible. H indicates hemorrhage control in bleeding victims, which also must occur expeditiously. RE denotes rapid extrication of victims to safety, with A indicating assessment by medical personnel. T indicates transport to definitive care. While taking such actions may seem obvious, on November 1, 2013, at the shooting at Los Angeles International Airport, a Transportation Security Administration officer was shot and left unattended for 33 minutes even though for much of that time there was no continued danger from the suspected shooter. Once transported to the medical center, the officer displayed no signs of life and was unable to be revived.6 Delays such as these are unacceptable. Law en-
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forcement must accept hemorrhage control as one of their core duties. The THREAT actions need to be consistently implemented. Membership for the Hartford Consensus panel was carefully and strategically determined to include leaders from law enforcement, emergency medical services, prehospital care, trauma care, and definitive care. The notion was that these leaders would be respected, credible, and able to influence the leadership of the national responder groups to not only endorse the Hartford Consensus but to enthusiastically commit to its principles. To do this, 2 priority areas require attention of the leadership of the nation’s responder groups. They will need to achieve among their constituents (1) solid commitment and cooperation and (2) fully integrated education, practice, and response. Now is the time for national leadership to implement a fully united approach to adopting the Hartford Consensus. This united approach will require that all responder groups come together for education. A national platform is needed to coordinate the effort and it makes sense that the professional organizations assume this role. However, rather than offering education only for their constituents, these organizations should consolidate leadership and offer the integrated education that is needed. A common curriculum for the joint implementation of THREAT is required. The education should be for all responders including the public. It should include a shared curriculum with integrated training and use of a common language and procedures understood by all responders. The National Association of Emergency Medical Technicians has taken a leadership role in this area by offering the Law Enforcement & First Response Tactical Casualty Care course.7 However, greater emphasis on education for the public is needed. Topics to be included in the curricula include safety, how to provide assistance, recognizing who is in charge, appropriate role enactment, appropriate response to commands, common language, expeditious access to victims and hemorrhage control, and rapid extrication, medical assessment, and transport to definitive care. The detail taught to each responder group will need to be specifically tailored to their roles. However, integrated education and practice are needed to overcome typical professional boundaries and promote a fully integrated response. How the curricula will be delivered is the next big challenge. What is needed now is finding creative ways to effectively and efficiently deliver the curriculum to all responders. For instance, the entertainment media can JAMA Surgery September 2014 Volume 149, Number 9
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archsurg.jamanetwork.com/ by a Western University User on 06/08/2015
891
Opinion Viewpoint
be used to inform and garner the support of the public. Carefully placed scenes in popular programs can reach millions of individuals with minimal expense. Finally, resources such as tourniquets and hemostatic dressings must be readily available to police officers and the public. One member of the Hartford Consensus has spoken directly to police chiefs in Los Angeles, California, Philadelphia, Pennsylvania, Houston, Texas, Washington, DC, Phoenix, Arizona, Dallas, Texas, New Orleans, Louisiana, and Tampa, Florida. As of mid-December 2013, they were finalizing the process of training and equipping their officers with hemorrhage control kits and training as recommended by
.com/politics/2012/07/mass-shootings-map. Accessed December 31, 2013.
ARTICLE INFORMATION Published Online: July 23, 2014. doi:10.1001/jamasurg.2014.189. Conflict of Interest Disclosures: None reported. REFERENCES 1. Wing N. We’ve had so many mass shootings in the U.S., we’ve had to redefine the term. Huff Post Politics website. http://www.huffingtonpost.com /2013/09/17/mass-shootings-us_n_3935978.html. Accessed December 31, 2013. 2. Follman M, Aronsen G, Pan D. A guide to mass shootings in America. http://www.motherjones
892
the Hartford Consensus. This represents more than 36 000 police officers. What is needed now is to have hemorrhage control equipment in all public places just as automatic external defibrillators are available. Just as citizen cardiopulmonary resuscitation has saved countless lives so can citizen first response save lives in intentional mass casualty incidents. Implementation of the principles of the Hartford Consensus through a fully integrated response and readily available tourniquets and hemostatic dressing will save lives. Efforts are now needed to secure the equipment and educate all first responders including the public.
3. Walls RM, Zinner MJ. The Boston Marathon response: why did it work so well? JAMA. 2013;309 (23):2441-2442. 4. Jacobs LM, McSwain N, Rotondo M, et al; Joint Committee to Create a National Policy to Enhance Survivability From Mass Casualty Shooting Events. Improving survival from active shooter events: the Hartford Consensus. Bull Am Coll Surg. 2013;98(6): 14-16. 5. Jacobs LM, Rotondo M, McSwain N, et al; Joint Committee to Create a National Policy to Enhance Survivability From Mass-Casualty Shooting Events.
Active shooter and intentional mass-casualty events: the Hartford Consensus II. Bull Am Coll Surg. 2013;98(9):18-22. 6. Abdollah T. LAX shooting: TSA officer Hernandez bled for 33 minutes at scene—report. http://www.nbcnews.com/_news/2013/11/15 /21471203-lax-shooting-tsa-officer-hernandez -bled-for-33-minutes-at-scene-report?lite. Accessed November 15, 2013. 7. National Association of Emergency Medical Technicians. Law Enforcement & First Response Tactical Casualty Care. http://www.naemt.org /education/LEFR-TCC/LEFRTCC.aspx. Accessed January 28, 2014.
JAMA Surgery September 2014 Volume 149, Number 9
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archsurg.jamanetwork.com/ by a Western University User on 06/08/2015
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VIEWPOINT
Lenworth M. Jacobs, MD, MPH Academic Affairs, Hartford Hospital, Hartford, Connecticut; and Traumatology and Emergency Medicine, University of Connecticut, Storrs. Karyl J. Burns, RN, PhD Academic Affairs, Hartford Hospital, Hartford, Connecticut.
Corresponding Author: Lenworth M. Jacobs, MD, MPH, Hartford Hospital, Academic Affairs, 80 Seymour St, Hartford, CT 06102 (lenworth.jacobs @hhchealth.org).
Improving Survival From Intentional Mass Casualty Incidents The Need for a National Curriculum With mass shootings happening more frequently, the epidemic of gun violence in the United States continues to produce death and suffering. 1,2 This is true even though considerable attention has been directed at mental health services and gun control. While gun violence and mass killings will continue to occur, steps can be taken to improve survivability. One area on which to focus is the prompt assessment and treatment of victims. Improved survivability requires changes in how law enforcement and all potential first responders, including the public, respond. As demonstrated at the Boston Marathon bombings, the public can, and will, act as first responders.3 While considerable effort will be needed to implement changes, change in this realm seems more likely to have a more expeditious and widespread effect. A national curriculum to improve the first actions of professional and lay responders is needed. Shortly after the killings at Sandy Hook Elementary School, in the spring of 2013, the American College of Surgeons commissioned the creation of The Joint Committee to Create a National Policy to Enhance Survivability From Mass Casualty Shooting Events. The committee held 2 meetings in the spring and fall of 2013 in Hartford, Connecticut. Within weeks of the first Hartford Consensus meeting, the bombings at the Boston Marathon took place. This led to the expansion of the committee’s focus on shooting events to include all intentional mass casualty incidents. The findings of these meetings became known as the Hartford Consensus. The overarching principle of The Hartford Consensus is that no one should die from uncontrolled hemorrhage.4,5 The Hartford Consensus uses an acronym THREAT to succinctly describe the major determinants for improving survivability from intentional mass casualty events.4,5 T stands for threat suppression and indicates that the perpetrator must be stopped as soon as possible. H indicates hemorrhage control in bleeding victims, which also must occur expeditiously. RE denotes rapid extrication of victims to safety, with A indicating assessment by medical personnel. T indicates transport to definitive care. While taking such actions may seem obvious, on November 1, 2013, at the shooting at Los Angeles International Airport, a Transportation Security Administration officer was shot and left unattended for 33 minutes even though for much of that time there was no continued danger from the suspected shooter. Once transported to the medical center, the officer displayed no signs of life and was unable to be revived.6 Delays such as these are unacceptable. Law en-
jamasurgery.com
forcement must accept hemorrhage control as one of their core duties. The THREAT actions need to be consistently implemented. Membership for the Hartford Consensus panel was carefully and strategically determined to include leaders from law enforcement, emergency medical services, prehospital care, trauma care, and definitive care. The notion was that these leaders would be respected, credible, and able to influence the leadership of the national responder groups to not only endorse the Hartford Consensus but to enthusiastically commit to its principles. To do this, 2 priority areas require attention of the leadership of the nation’s responder groups. They will need to achieve among their constituents (1) solid commitment and cooperation and (2) fully integrated education, practice, and response. Now is the time for national leadership to implement a fully united approach to adopting the Hartford Consensus. This united approach will require that all responder groups come together for education. A national platform is needed to coordinate the effort and it makes sense that the professional organizations assume this role. However, rather than offering education only for their constituents, these organizations should consolidate leadership and offer the integrated education that is needed. A common curriculum for the joint implementation of THREAT is required. The education should be for all responders including the public. It should include a shared curriculum with integrated training and use of a common language and procedures understood by all responders. The National Association of Emergency Medical Technicians has taken a leadership role in this area by offering the Law Enforcement & First Response Tactical Casualty Care course.7 However, greater emphasis on education for the public is needed. Topics to be included in the curricula include safety, how to provide assistance, recognizing who is in charge, appropriate role enactment, appropriate response to commands, common language, expeditious access to victims and hemorrhage control, and rapid extrication, medical assessment, and transport to definitive care. The detail taught to each responder group will need to be specifically tailored to their roles. However, integrated education and practice are needed to overcome typical professional boundaries and promote a fully integrated response. How the curricula will be delivered is the next big challenge. What is needed now is finding creative ways to effectively and efficiently deliver the curriculum to all responders. For instance, the entertainment media can JAMA Surgery September 2014 Volume 149, Number 9
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archsurg.jamanetwork.com/ by a Western University User on 06/08/2015
891
Opinion Viewpoint
be used to inform and garner the support of the public. Carefully placed scenes in popular programs can reach millions of individuals with minimal expense. Finally, resources such as tourniquets and hemostatic dressings must be readily available to police officers and the public. One member of the Hartford Consensus has spoken directly to police chiefs in Los Angeles, California, Philadelphia, Pennsylvania, Houston, Texas, Washington, DC, Phoenix, Arizona, Dallas, Texas, New Orleans, Louisiana, and Tampa, Florida. As of mid-December 2013, they were finalizing the process of training and equipping their officers with hemorrhage control kits and training as recommended by
.com/politics/2012/07/mass-shootings-map. Accessed December 31, 2013.
ARTICLE INFORMATION Published Online: July 23, 2014. doi:10.1001/jamasurg.2014.189. Conflict of Interest Disclosures: None reported. REFERENCES 1. Wing N. We’ve had so many mass shootings in the U.S., we’ve had to redefine the term. Huff Post Politics website. http://www.huffingtonpost.com /2013/09/17/mass-shootings-us_n_3935978.html. Accessed December 31, 2013. 2. Follman M, Aronsen G, Pan D. A guide to mass shootings in America. http://www.motherjones
892
the Hartford Consensus. This represents more than 36 000 police officers. What is needed now is to have hemorrhage control equipment in all public places just as automatic external defibrillators are available. Just as citizen cardiopulmonary resuscitation has saved countless lives so can citizen first response save lives in intentional mass casualty incidents. Implementation of the principles of the Hartford Consensus through a fully integrated response and readily available tourniquets and hemostatic dressing will save lives. Efforts are now needed to secure the equipment and educate all first responders including the public.
3. Walls RM, Zinner MJ. The Boston Marathon response: why did it work so well? JAMA. 2013;309 (23):2441-2442. 4. Jacobs LM, McSwain N, Rotondo M, et al; Joint Committee to Create a National Policy to Enhance Survivability From Mass Casualty Shooting Events. Improving survival from active shooter events: the Hartford Consensus. Bull Am Coll Surg. 2013;98(6): 14-16. 5. Jacobs LM, Rotondo M, McSwain N, et al; Joint Committee to Create a National Policy to Enhance Survivability From Mass-Casualty Shooting Events.
Active shooter and intentional mass-casualty events: the Hartford Consensus II. Bull Am Coll Surg. 2013;98(9):18-22. 6. Abdollah T. LAX shooting: TSA officer Hernandez bled for 33 minutes at scene—report. http://www.nbcnews.com/_news/2013/11/15 /21471203-lax-shooting-tsa-officer-hernandez -bled-for-33-minutes-at-scene-report?lite. Accessed November 15, 2013. 7. National Association of Emergency Medical Technicians. Law Enforcement & First Response Tactical Casualty Care. http://www.naemt.org /education/LEFR-TCC/LEFRTCC.aspx. Accessed January 28, 2014.
JAMA Surgery September 2014 Volume 149, Number 9
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archsurg.jamanetwork.com/ by a Western University User on 06/08/2015
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