Page 154 - Journal of Special Operations Medicine - Winter 2015

The Continuing Threat of
Intentional Mass Casualty Events in the U.S.

Observations of Federal Law Enforcement

William P. Fabbri, MD, FACEP, Director, Operational Medicine,
Federal Bureau of Investigation

he mission of the Hartford Consensus is to develop of rapid, dynamic engagement of active shooters as a
basic principles to improve victim survival by pro- lesson learned from Columbine. This approach by po-
Tmoting more effective local responses to active lice, intended to minimize the number of victims by
shooter incidents. From the inception of this project fol- bringing the incident to a more rapid conclusion, alters
lowing the 2012 Sandy Hook Elementary School trag- the problems faced by the trauma care system that will
edy, physicians from the Federal Bureau of Investigation receive casualties from the incident and has implications
(FBI) have worked with the American College of Sur- for both emergency medical services and receiving hos-
geons Committee on Trauma in applying what is known pitals. In addition to ending the incident more quickly,
about these incidents to the guidance developed by the this approach provides earlier access to victims requir-
consensus group. ing emergency hemorrhage control. The survival of this
subset of victims presents challenges to all participants
At the initial meeting in 2013, the Hartford Consensus in the response system, from point of injury to definitive
participants collectively observed that the elements of a care in the surgical suite. The Hartford Consensus views
more effective response to these events already exist in hemorrhage control as second only to engaging and de-
many communities. These components fall within the feating the shooter and as key to improving the survival
responsibilities of law enforcement, emergency medical of victims of active shooter incidents.
services, and rescue services, as well as the emergency
and surgical services of receiving hospitals. To be effec- The Hartford Consensus recommends that police de-
tive, these elements of the response must be organized, partments train and equip their officers to perform
coordinated, and deployed through plans compat- initial hemorrhage control measures using hemostatic
ible with the resources currently available in a given dressings and tourniquets. It also urges emergency medi-
community. cal and rescue services to train and equip their personnel
to work more closely with the police in terms of both
The capabilities of local public safety agencies, along time and distance. The over-arching result envisioned is
with the organizational philosophies and risk tolerance fewer injuries because of rapid termination of the ac-
of these agencies, vary across the country. Hospital ca- tive shooter threat, followed by rapid control of exter-
pabilities also vary widely with respect to the ability to nally compressible hemorrhage by police and emergency
receive multiple simultaneous trauma cases, a particu- medical and rescue services, with expedited identifica-
larly challenging problem in rural locations. In spite of tion and evacuation to surgical intervention of victims
these challenges, what we know about active shooter in- with suspected internal hemorrhage.
cidents tells us that these violent acts occur in communi-
ties of all sizes throughout the country and appear to be The law enforcement community has made substantial
increasing in frequency. This history supports the need gains in training and equipping officers to rapidly en-
for emergency action planning in every community. No gage the active shooter threat and provide emergency
single approach to improving survival in active shooter hemorrhage control when the threat is terminated. As
incidents is universally applicable; however, common part of a presidential directive following the Sandy
3
principles apply to response in any community. Hook Elementary School incident, the Department of
Justice sponsored an initiative based on standardized
4,5
Although these incidents have been well publicized for officer training for active shooter incident response.
almost a half century, the 1999 Columbine High School This program has provided training for approximately
incident was a sentinel event resulting in major changes 50,000 officers nationally, across all jurisdictions and
in police response to hostage situations involving armed without cost to their departments. The program is ex-
1,2
perpetrators. Many departments have adopted a model pected to reach a total of 80,000 officers within the

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