Page 154 - Journal of Special Operations Medicine - Spring 2016

messaging on external hemorrhage control with a spe- • Average of 2.7 gunshots per victim
cial emphasis on the use of extremity tourniquets. This • The case-fatality rate for CPMS was significantly
guidance is driven by the combat wounding pattern higher than that for combat (44.6% versus 9.11%)
and medical lessons learned from past military action • Only 20% of overall wounds were to the extremities
where 9% of deaths have been due to extremity hemor- (64% in combat)
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rhage and the overall case-fatality rate is less than 10%. • The site of fatal wounding was to the head or chest in
However, to have an informed basis on which to adopt 75% of cases (61% in combat)
military combat medical response algorithms for civil- • Only 7% of fatalities were found to have potentially
ian active shooter incidents, there must be evidence that survivable wounds. This is significantly lower than
supports the premise that military and civilian wound- the reported 24% in combat
ing patterns and injuries are similar. • The most common site of potentially survivable injury
was the chest (89%), not the extremity, as in combat.
There seems to be ready acceptance in the prehospital • In the study population, there were no deaths due
and trauma medical community of the assumption that, to exsanguination from an extremity, thus no deaths
despite obvious operational differences, the wounding that could have potentially been prevented with the
patterns, fatal injury, and required prehospital medical use of a tourniquet or external hemorrhage control.
interventions are similar between combat and civilian
public mass shootings. However, although the tissue The conclusion from this initial study of civilian active
physiology of ballistic wounding and the resulting sys- shooter wounding patterns confirms what is relative
temic physiologic response is the same, almost every- common sense. Because of the operational and popula-
thing else is different (e.g., age of victims, use of ballistic tion-based differences between civilian events and mili-
protection, comorbidities). Thus, directed medical inter- tary combat, the overall wounding and fatal wounding
ventions following civilian mass shootings may require a patterns are different than in combat. Does the fact that
different overall strategy and therapeutic emphasis than in the study population there were no deaths that could
that from combat to decrease the number of potentially have been prevented with a tourniquet imply that tour-
preventable deaths. niquets/external hemorrhage control in CPMS events
are unimportant? Emphatically no! Tourniquets and
Over the past 2 years, C-TECC cochair E. Reed Smith, simple hemorrhage control measures most definitely
executive committee member Geoff Shapiro, and Board have a role in improving survival but should no longer
of Directors member Babak Sarani have been conducting be the sole emphatic focus of national initiatives and
a review of requested official autopsies and medical direc- first responder and public education.
tor reports from civilian public mass shootings between
1983 and 2013, working with the hypothesis that fatal The study results indicate that chest injury, by far, is
wounding in civilian active shooter events differs from the most common, potentially survivable wound. As
combat and thus may require different therapeutic em- a result, a systematic approach that promotes not just
phasis. Although limited by many barriers to accessing hemorrhage control but the entire spectrum of civil-
the autopsies, through Freedom of Information Act re- ian TECC, adjusted to the scope of the provider, may
quests, the authors were able to obtain 139 autopsy/med- improve survival. Per TECC, in addition to immediate
ical examiner reports from 12 different CPMS events. patient access and external hemorrhage control (direct
pressure, tourniquets, and hemostatic agents), immedi-
This is the first study that specifically examines the over- ate medical care in the wake of a public mass shooting
all wounding, the fatal wounding, and the incidence of must include strategies to prevent further injury to the
potentially survivable wounds following civilian public wounded, simple airway management, recognition and
mass shootings. The study goal was to gain perspective management of declining respiratory function as a re-
on civilian fatalities in the same manner that Eastridge sult of penetrating trauma to the chest, proper position-
et al. did for the modern battlefield in 2010. Compar- ing of the casualty, efficient movement of the casualty,
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ing the results of the civilian autopsies with the results and prevention of hypothermia. Simple training with
from the combat deaths reported by Eastridge and co- that breadth of knowledge, along with improved opera-
workers, it is clear that fatalities following CPMS differ tional procedures to facilitate both rapid access to the
from combat fatalities in the mechanism of injury, over- wounded for medical first responders and rapid extrica-
all wounding pattern, the fatal wounding pattern, and tion to definitive care, will likely have the most mortality
the percentage of potentially survivable injuries. Some benefit for the few casualties with potentially survivable
of the results of the civilian data were as follows: but severe injuries following the next CPMS event.

• All wounds were due to gunshots (versus approxi- This study has been accepted for publication in the Journal
mately 80% blast and 20% gunshots in combat) of Trauma and Acute Care Surgery and the implications

138 Journal of Special Operations Medicine Volume 16, Edition 1/Spring 2016