Unfortunately, much of this campaign is being focused in soft-target facilities such as schools and churches/religious institutions. It is depressing to think that we have to prepare for acts of mass violence in areas where our children go to learn and where we go to worship; however, recent history of mass killings have demonstrated that these areas are statistically more likely to have higher numbers of casualties than other occupancy types.
I attended a training on active shooter incidents where the instructor said, “There is a reason that no one is attacking Texas Gun Shows” as the attackers are more likely to meet resistance at events such as those. Those that seek to commit mass killings desire to cause the maximum number of casualties in what will likely be a severely limited amount of time. Due to the highly dynamic nature of these types of incidents, there will likely be a delay in the arrival of medical professionals even when the law enforcement, fire, and medical agencies are fully cooperative, integrated and prepared.
When I went through my first medical training almost three decades ago, there was a heavy emphasis placed upon the concept of “the Golden Hour.” The Golden Hour is a term that was derived in the Korean and Vietnam Wars and suggested that a soldier that was shot on the battlefield had one hour to be delivered to a trauma surgeon if they had any hope of surviving their wounds. Unfortunately, the numerous casualties our armed services have experienced during the Global War on Terror have provided an incredible amount of data that has demonstrated the Golden Hour to be a misnomer.
A patient that has a gunshot wound involving a large vessel (especially an artery) can bleed out their entire blood volume in as little as three minutes. Without the application of early bleeding control techniques, we can deliver that patient to a surgeon at the outer edge of the Golden Hour, but they are likely to have died 57 minutes before they arrived at the surgical suite. As Dr. Nicholas Senn, founder of the Association of Military Surgeons of the United States, wrote: “The fate of the wounded lies in the hands of the ones who apply the first dressing.” In other words, many of our soldiers or patients involved in these domestic acts of violence do not have an hour, but only mere minutes to have life saving bleeding control techniques applied. Because it will take more than a few minutes to get medical professionals to a patient that is in a large facility during an active shooter incident, a significant number of seriously injured victims can die before they reach the hospital. The help that bystanders offer can often mean the difference between life and death.
My fire department has recently completed training every teacher, administrator and bus driver in every school in the county on bleeding control (BCON) techniques. Additionally, we have placed BCON kits in every school. While it is sad that this is necessary, our school staffs are fully trained, equipped and empowered to apply the first dressing at an incident that we pray never occurs. While these response techniques are paramount, it is also important to discuss prevention techniques with our education professionals. Research has demonstrated that 88 percent of active shooters 17 years of age or younger have intentionally or unintentionally revealed clues to a third-party about feelings, thoughts, fantasies, attitudes or intentions that may signal the intent to commit a violent act (known as “leakage”). When a concerning behavior was demonstrated by these active shooters it was observed by a peer 92 percent of the time and a teacher/school staff 75 percent of the time. We should remind our teachers and school staffs that along the lines of our Department of Homeland Security’s directive for continual vigilance, “if you see something, say something.” They should be encouraged to report any concerning behaviors or leakage to their school resource officers or the local law enforcement agency.
Next, we need to consider the protective actions in our schools. Many follow “secret” codes that mirror what is used in health care facilities. “Code Red” may mean fire in the building, while “Code Blue” means that there is a fight going on somewhere in the building (or cardiac arrest in the health care facility). Herein lies the problem with codes. They are not uniform and many of the full-time teachers may not remember what each means much less the handful of substitute teachers that are in every educational facility throughout our great state every day. Our school district adopted the terminology recommended by the I Love You Guys! Foundation (founded by the parents of Emily Keyes – the sole victim at the Platte Canyon, CO shooting in 2006 – her last text to her parents just before she was killed was “I love you guys”). The I Love You Guys! Foundation recommends four protective actions. They are:
- Evacuate – in the event of a fire, bomb threat, etc.
- Shelter – in the event of a tornado, earthquake, etc.
- Lockout – in the event of a possible threat OUTSIDE the building, but in the vicinity
- Lockdown – in the event of a threat INSIDE the building
During a lockout, exterior doors are locked, everyone outside of the building is brought inside, but it is business as usual inside the school. Children change classes, people move freely about the interior of the building, but no one goes outside. The exterior doors remain locked, no one is allowed inside, and any law enforcement presence inside the building raise their awareness to potential threats.
Lockdown on the other hand is when teachers should remember locks, lights, out of sight. This is the point where teachers should lock their classroom doors (and barricade them if possible), turn off the lights in the classroom, and position themselves and their students in a place in the classroom that is out of sight of the window on the door. Again, most shooters are attempting to cause the maximum amount of damage in a limited amount of time. When they encounter a locked door with the lights off and no visible occupants inside, they are likely to move on to another target. Using the FBI recommendations for being involved in an active shooter situation (RUN – HIDE – FIGHT), we should also prepare our school staffs for what to do if the shooter enters their room (the last option, fight). They should act with aggression, improvise weapons and do everything possible to neutralize the shooter.
We should also prepare our teachers/school staff and others on what it will be like when law enforcement arrives. Law enforcement’s first priority is to ensure that the shooter is neutralized. We should be sure that our teachers/school staff, students, and others keep their hands visible, do not point or yell at the law enforcement officers and follow their commands.
Finally, we have to provide our bystanders with the specifics of BCON. There are four objectives to consider if someone is injured during an active shooter incident. First, they should ensure their own safety. They should not attempt to help others unless it is safe to do so and effort to protect themselves from bloodborne pathogens by wearing gloves. This is simple numbers. If we have one student injured and a teacher takes an unnecessary risk to save them and becomes injured, we now have two patients. If a third person is injured attempting to help the injured teacher, we now have three patients, and so on.
Second, we need to identify the injury by exposing the wound. Arterial bleeding is bright red blood that is spurting or pumping from the wound (this is life threatening). Venous bleeding is dark red blood that steadily flows (can be life threatening in large vessels). Capillary bleeding is oozing blood with very little volume (is likely not life threatening).
Third, we need to stop the bleeding. Tourniquets can be used for extremity wounds (arms and legs) and should be placed between the wound and the heart, tightened until the bleeding stops, secured and not loosened. If a tourniquet is not immediately available, direct pressure can be used until a tourniquet can be placed (this is likely more effective than attempting to make a tourniquet from available materials). Direct pressure/wound packing can be used for any junctional wounds (pelvis, armpit, neck).
When using wound packing, remember to hold pressure for three minutes when using hemostatic dressings and 10 minutes if using plain gauze. Direct pressure/wound packing can also be used for any internal injuries (injuries to the chest and abdomen). These patients will also need to be triaged to the front of the line when transportation begins.
When injuries to the airway occur, assess the patient’s level of consciousness. For conscious patients, allow them to assume any position that allows them to manage their own airway (this position is likely not supine or lying down). For unconscious patients, roll them into the recovery position (on their side). This will prevent their airway from being blocked by their tongue or an accumulation of blood and other fluids. Fourth, we need to keep the victim warm. Studies indicate that for every degree of body temperature lost, the body loses a high percentage of its clotting abilities. This will then lead to continued blood loss, continued temperature decrease, and additional loss of the body’s clotting abilities. It is much easier to prevent hypothermia and exsanguination than it is to reverse it. Use blankets, coats, sweaters, etc. to keep the victim as warm as possible.
The BCON kits we placed in every school in our county contain gloves (for body substance isolation), a tourniquet (for life-threatening extremity bleeding), a hemostatic dressing and wrap (for life-threatening junctional or internal wounds), and a foil blanket to keep the patient warm. There has been much discussion on where to place the BCON kits. Given the size of many schools, churches/religious institutions, etc., the decision should be made considering the building layout, staffing patterns and number of occupants.
Louis Pasteur (1822-1895), a French biologist and chemist known as the “father of microbiology,” once said, “Fortune Favors the Prepared Mind.” While we all hope a mass killing incident does not occur in our jurisdiction, we must be prepared. With the Stop the Bleed! Campaign in mind, we should prepare our citizens so that hopefully fortune favors us.
Be safe and do good.