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Empowering the Public to Improve Survival in Mass Casualty Events

Jacobs, Lenworth M. MD, MPH, FACS; Warshaw, Andrew L. MD, FACS; Burns, Karyl J. PhD

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doi: 10.1097/SLA.0000000000001517
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The terrorist bomb explosions at the Boston Marathon resulted in the deaths and severe injuries of hundreds of citizens. The immediate action of citizen bystanders to attempt to stop exsanguinating hemorrhage was commendable and demonstrated that citizen bystanders are willing to render aid. Ideally, these events should be prevented; however, we live with the perils of terrorism, the actions of deranged strangers, and the dangerous impulses of friends and relatives. The availability of high-velocity firearms, easily constructed bombs, and simple implements such as hunting or kitchen knives allows harmful actions to be executed with dire consequences.

In the United States, between 2000 and 2008, there was an average of 5 active shooter incidents each year; since 2009 this number has tripled and there has been almost a 150% increase in the number of individuals shot and killed in the context of these events.1 Although bombings have been rare in the United States since the 9/11 attacks, when they do happen, they can have devastating results.2 In Boston, 3 people died and a total of 264 individuals were injured.3,4 Many, with severe bleeding, were transported to 6 level I Boston trauma centers.4 Furthermore, weapons that typically have not been used to injure a large number of people are now being used. At a high school near Pittsburgh, a student stabbed 22 individuals, several of whom required surgery.5

To increase survival in mass casualty events, a new organization and coordination of responses, including immediate bystander participation, is needed. Changes are needed as the traditional response is no longer adequate. One reason is that law enforcement and emergency medical responses have operated separately. They have been directed under separate command authorities and have used different language and codes. The consequence has been that victims have not been attended to until law enforcement secures the threat. Emergency medical services (EMS) personnel typically wait in the cold zone, a safe area outside the perimeter of the environment until law enforcement has suppressed the threat and the danger is eliminated. To save lives from hemorrhage, immediate control of bleeding must be accomplished even if the victim is in the hot zone, the area of danger containing the uncontrolled threat. As soon as possible the victim must be transferred to the warm zone or ideally the cold zone. The warm zone is an area that is not in direct immediate danger, but has not been declared completely safe. The cold zone is a safe area for triaging, staging, and transportation of the patients.

Another needed change is that civilian bystanders known as immediate responders have not been recognized and incorporated into training and planning for hemorrhage control. Bystanders are a resource that should not be ignored if survivability is to be maximized. Bystanders are immediately available followed by law enforcement. Immediate actions by both groups can save lives.

These changes require specific steps to be taken. The response doctrine must be transformed to enhance the interface between law enforcement, fire/rescue, EMS, and civilian immediate responders to optimize the care of victims. A comprehensive integrated response that functions through joint protocols with unified command and a common language is needed. Response philosophy must be that the timely care of victims is a shared responsibility of all responders. It is no longer acceptable for law enforcement not to render care, and it is no longer acceptable for EMS to stage and wait. Entry into the warm zone by non-law enforcement responders may be required. Law enforcement will be in the warm and hot zones as maybe civilian bystanders. Some civilians may not wish to render aid or may not be able to do so. However, it is critical to empower citizens who want to assist in controlling hemorrhage.

For law enforcement and civilian immediate responders to be effective at hemorrhage control, they must have the appropriate training and equipment. Many municipalities have already begun training police officers about bleeding control and supplying them with equipment. Continued training is required until every police officer can effectively control hemorrhage. They need to train and practice with EMS each understanding their different roles, but each sharing responsibility for the immediate control of hemorrhage.

Training of civilians in hemorrhage control should become a public health priority. Just as there are programs to teach civilians cardiopulmonary resuscitation, the use of automatic external defibrillators (AEDs), and first aid, there should be bleeding control training for all who desire to have this ability. Although training for hemorrhage control is being offered in certain locales including Boston,6 it needs to become commonplace across the nation. The National Association of Emergency Medical Technicians has begun to offer the Bleeding Control for the Injured (B-CON) course to civilians.7

Any bystander can initiate bleeding control by applying direct pressure to the wound. The most important piece of equipment that everyone has is their hands. Although improvised tourniquets are not the best, it can be expected that the public will use them. EMS should be prepared to encounter belts, pieces of clothing, and other makeshift tourniquets. Ideally, just as AEDs are available in public places, hemostatic dressings and commercial tourniquets should also be accessible. Public places should have bleeding control bags alongside AEDs. At Hartford Hospital, over 200 staff have been trained in tourniquet application and 5 bleeding control bags have been placed next to AEDs throughout the facility.

Beginning in 2013, shortly after the Sandy Hook shootings, a group of concerned representatives from public safety organizations including law enforcement, fire, prehospital care, trauma care, and the military participated in 3 meetings in Hartford, CT. The goal was to recommend strategies to increase survivability in mass casualty shootings. The ideas put forth at these meetings are known as the Hartford Consensus. The overarching principle of the Hartford Consensus is that no one should die from uncontrolled bleeding. The actions needed to save lives are summarized with the acronym THREAT with T standing for threat suppression, H for hemorrhage control, RE for rapid extrication to safety, and T for transport to definitive care.8

To effectively implement THREAT, a 3-phased coordinated approach is needed. First, bystanders can be immediate responders. Second, law enforcement and EMS/fire/rescue must render care as soon as possible. Third, victims must be transported rapidly to the nearest appropriate hospital for definitive care. This means that EMS may need to enter warm zones to stop external bleeding or expeditiously remove and transport victims with internal hemorrhage.

Although the Hartford Consensus has gained national attention by prominent organizations such as the Federal Emergency Management Agency, the U.S. Fire Administration, the Federal Bureau of Investigation (FBI), the Major Cities Chiefs Police Association, the Department of Homeland Security, and the National Security Council, much more remains to be accomplished. In January 2015, a bystander in San Diego applied an improvised tourniquet to the severed extremity of a pedestrian who had been struck by a motorcycle. The 911 dispatcher instructed that the tourniquet be removed. It was removed, after which the victim continued to bleed and lost consciousness. He later died at the hospital.9 Reports such as this highlight the need for all responders to know how to correctly use direct pressure, hemostatic dressings, and tourniquets.

Ideally, active shooter and intentional mass casualty events should be prevented. When they do occur, eliminating the threat and increasing survival become the primary goals. Controlling bleeding that occurs in the prehospital environment needs to be standard care that can be rendered by any trained individual. The public needs to be empowered to act as immediate responders to stop hemorrhage. They should be a part of response that is integrated and coordinated. Reorganization of the current response configuration must include 3 levels of responders: (1) immediate responders previously known as bystanders, (2) organized EMS responders who have all the necessary training and equipment including bleeding control kits, and (3) rapid transportation for definitive treatment. Planning and active drills must include immediate responders interacting with all prehospital providers. Empowerment of the public, education of all responders, and availability of equipment for bleeding control are critical to increasing survival from mass casualty events.


1. Attorney General Eric Holder delivers remarks at the International Association of Chiefs of Police annual conference. Justice News, October 21, 2013. Available at: Accessed April 7, 2015.
2. Bergen P, Rowland J. Why terrorists bombings have been rare in the U.S. in past decade. April 17, 2013. Available at: Accessed April 7, 2015.
3. Reuters. Boston marathon bombing injury total climbs to 264, officials say. April 23, 2013, updated June 23, 2013. Available at: Accessed April 8, 2015.
4. FEMA. Lesson learned. Boston marathon bombings: hospital readiness and response. Available at: Accessed May 19, 2015.
5. BBC US & Canada. Up to 22 people stabbed at Pennsylvania high school. April 10, 2014. Available at: Accessed April 7, 2015.
6. Fox JC. Teachers learn lesson on how tourniquets can save lives. June 4, 2015. Available at: Accessed August 12, 2015.
7. National Association of Emergency Medical Technicians. What is B-CON. Available at: Accessed April 8, 2015.
8. 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; 98:14–16.
9. Valdez E. San Diego 911 dispatcher's medical instructions questioned. January 13, 2015, updated January 14, 2015. Available at: Accessed April 8, 2015.
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