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the Afghan war. Can J Surg. 2011;54(6):S118-S123. doi:10.1503/ New Orleans), Dr. Richard Carmona (former Surgeon General of
cjs.025011 the United States), Dr John Holcomb (the driving force behind
Sabate-Ferris A, Pfister G, Boddaert G, et al. Prolonged tactical many of the Department of Defense’s advances in trauma care
tourniquet application for extremity combat injuries during war during the recent conflicts), Dr. Frank Butler (Chair of the DoD’s
against terrorism in the Sahelian strip. Eur J Trauma Emerg Surg. Committee on TCCC), and Dr Ronnie Stewart (Chair of the ACS
2022;48(5):3847–3854. doi:10.1007/s00068-021-01828-4 Committee on Trauma). Also included were leaders from law en-
Tien HC, Jung V, Rizoli SB, Acharya SV, MacDonald JC. An evalua- forcement agencies (Drs. Dave Wade and Bill Fabbri from the FBI
tion of tactical combat casualty care interventions in a combat en- and Dr. Alex Eastman, from Dallas SWAT) as well as fire service
vironment. J Am Coll Surg. 2008;207(2):174–178. doi:10.1016/j. agencies. The Hartford Consensus Group held a series of three
jamcollsurg.2008.01.065 meetings in 2013–2015 and published three advisory statements,
Usero-Pérez C, González Alonso V, Orbañanos Peiro L, Gómez Cre- which were compiled into the Hartford Consensus Compendium
spo JM, Hossain López S. Implementación de las recomendaciones
del Consenso de Hartford y Tactical Emergency Casualty Care (Levy 2016, Jacobs 2014, Jacobs 2013). This compendium has
(TECC) en los servicios de emergencia: revisión bibliográfica [Im- now been released as a Special Communication from the ACS.
plementation of the Hartford Consensus and Tactical Combat Ca- In the first of the Hartford Consensus publications, Dr. Jacobs and
sualty Care recommendations in emergency services: a review of the author group noted:
the literature]. Emergencias. 2017;29(6):416–421.
Vysokovsky M, Avital G, Betelman-Mahalo Y, et al. Trends in prehos- One example of the lifesaving potential of TCCC guidelines
pital pain management following the introduction of new clinical is the renewed focus on prehospital tourniquet use. Be-
practice guidelines. J Trauma Acute Care Surg. 2021;91(2S Suppl fore TCCC concepts were introduced, military medics were
2):S206-S212. doi:10.1097/TA.0000000000003287 taught that a tourniquet should be used only as a last re-
Wang X, Xia D, Zhou P, Gui L, Wang Y. Comparing the performance of sort to control extremity hemorrhage. It is not surprising to
tourniquet application between self-aid and buddy-aid: in ordinary note that a study of 2,600 combat fatalities from the Vietnam
and simulated scenarios. Am J Transl Res. 2021;13(6):6134–6141. conflict and a second study of 982 fatalities from the early
Webster S, Barnard EBG, Smith JE, Marsden MER, Wright C. Killed years of conflicts in Afghanistan and Iraq found that the inci-
in action (KIA): an analysis of military personnel who died of their dences of death from extremity hemorrhage were essentially
injuries before reaching a definitive medical treatment facility in unchanged, at 7.4% and 7.8%, respectively…..However, after
Afghanistan (2004-2014). BMJ Mil Health. 2021;167(2):84–88. widespread implementation of the tourniquet recommenda-
doi:10.1136/bmjmilitary-2020-001490
tions from the TCCC guidelines, deaths from extremity hem-
orrhage became uncommon. A recent comprehensive study
The Hartford Consensus and the of 4,596 US combat fatalities from 2001 to 2011 noted that
ACS Stop the Bleed Program the incidence of preventable deaths from extremity hemor-
In recent years, civilian law enforcement officers and EMS re- rhage had decreased remarkably to 2.6%. . . . The number
sponders have been called to bombing incidents, school and mall of US lives saved from this single intervention has been esti-
shootings, and other terror attacks that present tactical situations mated to be between 1,000 and 2,000. (Jacobs 2013 – JACS)
similar in some respects to those encountered on battlefields. The
threat of ongoing hostile fire, treating multiple casualties under The Hartford Consensus recommended that all professional first
cover, and prolonged evacuation times have all come into play. responders, to include EMS systems, law enforcement officers, and
Even in urban settings, getting to, treating, and transporting ca- firefighters, should carry tourniquets and hemostatic dressings
sualties can require tactics and training outside the parameters while carrying out their professional duties (Jacobs 2013 – JACS,
of many standard EMS protocols. The mass casualty incidents at Jacobs 2013 – J Trauma).
Columbine High School, Virginia Tech, and Sandy Hook Elemen-
tary School are examples in point. More widespread adoption of This was a remarkable rethinking of the long-held position that
applicable TCCC guidelines into tactical EMS training programs, tourniquet use in the prehospital phase of care for trauma victims
and application of these principles to tactical law enforcement should be avoided because it would result in an unacceptable in-
operations may result in better tactical flow and additional lives cidence of limb loss due to tourniquet ischemia. The work done
saved (Butler and Carmona 2012). by COL John Kragh had clearly proven that this perception was
false and that prehospital tourniquets were safe, effective, and life-
The individual most responsible for helping to facilitate the transla- saving should the casualty actually have a major vascular injury
tion of the military success with tourniquets and hemostatic dress- (Kragh 2013, Kragh 2009, Kragh 2008). The recommendations
ings to the civilian sector is Hartford, Connecticut, trauma surgeon of the Hartford Consensus were reinforced by the findings of the
Lenworth Jacobs (Butler 2015 – TCCC and HC). In 2013, Dr. Ja- Prehospital Subcommittee of the American College of Surgeons
cobs convened the Hartford Consensus working group (the formal in 2014. That group, led by Dr. Eileen Bulger, also agreed that
name of the group was the “Joint Committee to Create a National the military experience with TCCC in Iraq and Afghanistan had
Policy to Enhance Survivability from Active Shooter and Intentional proven tourniquets and hemostatic dressings had been effective in
Mass Casualty Events.”) With Dr. Jacob’s advocacy, the Hartford saving limbs and had caused only minimal morbidity when used
Consensus was chartered by the American College of Surgeons for short periods of time (Bulger 2014). The Hartford Consensus
(ACS) to identify measures that would help to improve survival for was the springboard for the Stop the Bleed program, which was
the victims of mass casualty incidents. He undertook this effort af- implemented by the ACS with the active support and endorsement
ter the governor of Connecticut asked for his assistance in reviewing of the White House (Levy 2016).
the tragic deaths in the Sandy Hook shootings and making recom-
mendations about what measures might be undertaken to improve Both the everyday trauma that occurs in the U.S. as well as the dra-
survival in future mass shooting incidents. Dr. Jacobs convinced the matic increase in terrorist attacks and so-called “active-shooter”
leadership of the ACS that the College should strongly advocate for incidents create the potential for a great many additional lives
improving the prehospital care for the victims of these incidents, to be saved by using TCCC and Stop the Bleed concepts. Public
primarily through the first responder use of tourniquets and hemo- awareness of such events and the ACS and White House advocacy
static dressings to control external hemorrhage. for the Stop the Bleed program is already paying significant divi-
dends in lives saved and has caused an acceleration of the transla-
The Hartford Consensus Group included representatives from tion of these two lifesaving interventions from the military to the
the White House, the Department of Defense, the Department of civilian sector (Jacobs 2016, Levy 2016).
Homeland Security, and the ACS. The participants included na-
tional leaders in trauma surgery, Dr. Jacobs, the late Dr Norman Two other factors that have also been important in accelerating this
McSwain (trauma director at the Spirit of Charity Hospital in translation are the development of the civilian Tactical Emergency

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