Page 61 - Journal of Special Operations Medicine - Fall 2015

services (EMS) agencies have re-evaluated their response Figure 3 First care provider applying direct pressure for
profiles and capacity for combined operations, many hemorrhage control.
have yet to implement “warm zone” or indirect-threat
care operations. The result can be significant delays in pa-
tient care. Considering the complex factors that may limit
professional responder access to casualties during AVIs,
the FBI active shooter study concluded with the follow-
ing: “Even when law enforcement was present or able to
respond within minutes, civilians often had to make life
and death decisions, and, therefore, should be engaged in
training and discussions on decisions they may face.” 10

For example, the after-action reports of the Aurora, Printed with permission of John Tlumacki
Colorado, theater shooting described the initial fire de-
partment’s first responders being met with 1,400 frantic
civilians fleeing the scene with injured patients mixed
among the healthy. The Aurora Fire Department re-
ported that the scene was so chaotic they were unable
to approach the theater secondary to the overwhelming is to “Run, Hide, Fight.” While the DHS/FBI guid-
33
number of people in the parking lot. As a result, law ance is prudent and easily taught, the Boston bombing
28
enforcement and civilians provided the bulk of the ini- further reaffirmed that bystanders/victims can provide
tial trauma care interventions. 29 critical manpower, expertise, and resources for casualty
management and evacuation if a simple but effectively
Perhaps more than any event in recent memory, the trained multiagency plan is in place. Repeated incidents
2013 Boston bombing demonstrates that bystanders ac- including, but not limited to, the Virginia Tech shooting,
tually play a critical role as the FCPs in AVIs. In the the Aurora massacre, the Washington, DC, Navy Yard
30
seconds after the bombing, law enforcement moved im- shooting, and the Los Angeles Airport shooting demon-
mediately to threat-mitigation mode and the medical strate that after the threat is reduced, bystanders have
first responders mobilized quickly. However, the sheer access to casualties long before medical first responders.
number of ambulatory casualties and the ongoing secu- The potential for using trained teachers, public work-
rity threat restricted first-responder movement (Figure ers, or even students to provide immediate hemorrhage
3). This restriction resulted in “bystanders” functioning control at the point of injury has profound implications
as FCPs for huge numbers of casualties. Popular press and potential to further reduce morbidity and mortality.
reports, discussions with prehospital providers and law
enforcement, and a review of the scientific literature re- As with most training efforts, the key to success resides
veal a critical role played by civilian FCPs, particularly with the planning, execution, and delivery of the pro-
in providing primary hemorrhage control for victims gram. The RFR program demonstrates that common lan-
during the aftermath of the bombing. 31 guage and standardized training are vital when creating
successful programs, and consistent repetitive training
The importance of FCPs should not be unexpected. provides the desired “conditioning” response for when
Analogous cardiac arrest data have shown profound real-world events occur. Using the RFR model, the com-
changes in mortality with early intervention. Two re- mon language of TECC allows for tiered training, coor-
gional studies in the United States showed an 80-fold dinated response, program scalability, and sustainability
increase in survival for sudden cardiac arrest (SCA) vic- throughout the community. The FCP programs should
tims who receive early bystander cardiopulmonary re- provide familiarization training in hemorrhage control,
suscitation. As most EMS personnel may not be able recovery position, basic casualty movement, tactics to
32
to reach an SCA victim within the first 5 minutes, rapid secure their environment (e.g., barricading doors), and
response and care from bystanders is paramount for how to activate/ respond to law enforcement presence.
preventing death from SCA. In AVI, similar delays in Select FCP groups such as teachers should be expected
EMS provision of point-of-wounding care are common. to demonstrate proficiency in hemorrhage control, in-
cluding direct pressure, pressure-dressing application,
The fundamental question remains of how to create an and tourniquet application.
effective FCP program that integrates with the broader
professional first-responder protocols and procedures. Traumatic injury is the leading cause of death in the US
The Department of Homeland Security (DHS) and FBI population ages 1–44 years. The success of existing
34
guidance for the private sector and citizens during AVIs programs such as community basic life support (BLS)

Community Approach to Reducing Mortality From AVIs 49