Page 169 - Journal of Special Operations Medicine - Winter 2015

Intentional Mass Casualty Events
Implications for Prehospital Emergency Medical Services Systems

Matthew J. Levy, DO, MSc, FACEP, Senior Medical Officer,
Johns Hopkins Center for Law Enforcement Medicine

omestic and international events of mass violence, tension pneumothorax and airway obstruction. The
including active shooter and intentional mass casu- work of these groups has helped shape national-level
Dalty incidents, warrant unique response consider- policy and guidance documents, most recently including
ations for prehospital emergency medical services (EMS) the U.S. Department of Homeland Security’s June 2015
and first responder agencies. Regardless of whether an First Responder Guide for Improving Survivability in
EMS system serves an urban, suburban, or rural com- Improvised Explosive Device and/or Active Shooter In-
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munity, and independent of the EMS system’s architec- cidents. This evidence-based document calls for a re-
ture, these events represent a complex and challenging alignment of traditional emergency services practices to
interagency response scenario for which all EMS agen- improve victim survivability and responder safety. It fo-
cies must be prepared. These events have resulted in cuses on three specific areas: hemorrhage control, pro-
multiple casualties with both blunt and penetrating in- tective equipment, and response/incident management.
jury patterns.
A Paradigm Change
For any critically ill or injured patient, survival is often Enhanced readiness to respond to active shooter and in-
dependent on prompt and immediate access to lifesav- tentional mass casualty events necessitates a fundamental
ing interventions. The principal concept of THREAT change in the operational paradigm of many prehospital
(Threat suppression, Hemorrhage control, Rapid Extri- EMS agencies. The conventional EMS training and prac-
cation to safety, Assessment by medical providers, and tice of waiting for a scene to be safe before medical per-
Transport to definitive care), as outlined in the Hartford sonal enter the scene conflicts with the need for rescuers
Consensus documents, provides an organized and sys- to access those victims who have potentially survivable
tematic approach to the priorities of responding emer- injuries before they die. Every minute that goes by fol-
gency personnel. Specifically, the notion of hemorrhage lowing an event, the probability of survival decreases for
control represents a fundamental tenet of responder ca- critically injured patients. Lessons learned from previous
pability for both lay and professional rescuers, as well incidents have taught us that waiting for the entire scene
as for EMS system readiness. Past experience has dem- to be totally safe and without the possibility of threat re-
onstrated that those casualties with mild injuries tend to sults in more lives lost. We need to fundamentally change
self-evacuate. These prior events also have demonstrated how we in EMS think about response.
that civilian immediate responders will often render aid
to more seriously injured victims. The role of immediate Planning and Operational Considerations
responders in providing immediate hemorrhage control The safety and accountability of all responders must be
cannot be underestimated and is a vital link in the chain in the forethought of all personnel responding to ac-
of survival for victims. tive shooter and mass casualty incidents. Rescuers must
maintain situational awareness of the dynamic nature of
Beyond theory, the tenets behind THREAT have been these incidents, including the possibility of ambush and
proven both on the battlefield and in the wake of some secondary devices intended to harm responding person-
of the worse recent domestic attacks in the U.S. This con- nel. Rapid changes in conditions and the overarching
cept aligns naturally with recommendations and guide- need to evacuate personnel and patients may require in-
lines of other allied groups, including the U.S. military’s cident commanders to call for real-time adjustments to
Committee on Tactical Combat Casualty Care and the the delivery of lifesaving interventions.
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civilian Committee for Tactical Emergency Casualty
Care. Both groups emphasize the importance of early Responders should be encouraged to approach and
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hemorrhage control, in addition to the ability to ad- evaluate potentially volatile situations in terms of calcu-
dress immediately correctible causes of death, including lated risk versus benefit. This concept is not foreign to

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