Geoff Shapiro

The profile of wounding in civilian public mass shooting fatalities.

BACKGROUND The incidence and severity of civilian public mass shootings (CPMS) continue to rise. Initiatives predicated on lessons learned from military woundings have placed strong emphasis on hemorrhage control, especially via use of tourniquets, as means to improve survival. We hypothesize that both the overall wounding pattern and the specific fatal wounds in CPMS events are different from those in military combat fatalities and thus may require a new management strategy. METHODS A retrospective study of autopsy reports for all victims involved in 12 CPMS events was performed. Civilian public mass shootings was defined using the FBI and the Congressional Research Service definition. The site of injury, probable site of fatal injury, and presence of potentially survivable injury (defined as survival if prehospital care is provided within 10 minutes and trauma center care within 60 minutes of injury) was determined independently by each author. RESULTS A total 139 fatalities consisting of 371 wounds from 12 CPMS events were reviewed. All wounds were due to gunshots. Victims had an average of 2.7 gunshots. Relative to military reports, the case fatality rate was significantly higher, and incidence of potentially survivable injuries was significantly lower. Overall, 58% of victims had gunshots to the head and chest, and only 20% had extremity wounds. The probable site of fatal wounding was the head or chest in 77% of cases. Only 7% of victims had potentially survivable wounds. The most common site of potentially survivable injury was the chest (89%). No head injury was potentially survivable. There were no deaths due to exsanguination from an extremity. CONCLUSION The overall and fatal wounding patterns following CPMS are different from those resulting from combat operations. Given that no deaths were due to extremity hemorrhage, a treatment strategy that goes beyond use of tourniquets is needed to rescue the few victims with potentially survivable injuries. LEVEL OF EVIDENCE Prognostic/epidemiologic study, level IV; therapeutic/care management study, level V.

Building community resilience to dynamic mass casualty incidents: A multiagency white paper in support of the first care provider.

N and manmade disasters are becoming more common and are creating increasingly complex response challenges. The current US emergency responsemodel relies heavily on the availability and expertise of highly trained public safety agencies. Too often, this leads the public to assume that professional emergency medical care will be immediately available. Unfortunately, there are frequent delays in first responders accessing victims, especially in complex high-threat events such as the attacks inNorway, theAurora shootings, theVirginiaTech shooting, the Westgate Mall attack, and most recently, the shootings at Umpqua College. Initiatives, such as theArlingtonRescue Task Force and 3-ECHO program, are creating ‘‘warm zone/indirect threat care’’ operational paradigms for first responders and are an important first step in shortening the time from injury to first medical intervention. However, despite aggressive and expedient deployment of professional medical providers, there remains a significant time gap from point of injury to lifesaving intervention that only first care providers (FCPs) can address. As noted in the original Tactical Emergency Casualty Care (TECC) guidelines and the Hartford Consensus III statement, empowered and trained community members can serve a critical role as FCPs during the initial moments after complex and dynamic disasters. The Hartford Consensus calls for ‘‘empowering the public to provide emergency care.’’ These FCPs often have immediate access to severely injured victims and can provide time-sensitive, lifesaving interventions. Appropriately trained and equipped, the FCP can be the first link in the trauma chain of survival. Public safety and first response agencies should acknowledge this operational reality and should lead the effort to integrate the FCP into the whole of community crisis response plans built on the tiered application of the civilian TECC medical guidelines. The purpose of this article was to render recommendations of a group of subject matter experts in civilian active shooter events regarding initial scene management and how to quickly and efficiently render care to the wounded using FCPs and the principles enumerated in TECC.

Fatal Wounding Pattern and Causes of Potentially Preventable Death Following the Pulse Night Club Shooting Event

Abstract Background: Mortality following shooting is related to time to provision of initial and definitive care. An understanding of the wounding pattern, opportunities for rescue, and incidence of possibly preventable death is needed to achieve the goal of zero preventable deaths following trauma. Methods: A retrospective study of autopsy reports for all victims involved in the Pulse Nightclub Shooting was performed. The site of injury, probable site of fatal injury, and presence of potentially survivable injury (defined as survival if prehospital care is provided within 10 minutes and trauma center care within 60 minutes of injury) was determined independently by each author. Wounds were considered fatal if they involved penetration of the heart, injury to any non-extremity major blood vessel, or bihemispheric, mid-brain, or brainstem injury. Results: There were an average of 6.9 wounds per patient. Ninety percent had a gunshot to an extremity, 78% to the chest, 47% to the abdomen/pelvis, and 39% to the head. Sixteen patients (32%) had potentially survivable wounds, 9 (56%) of whom had torso injuries. Four patients had extremity injuries, 2 involved femoral vessels and 2 involved the axilla. No patients had documented tourniquets or wound packing prior to arrival to the hospital. One patient had an isolated C6 injury and 2 victims had unihemispheric gunshots to the head. Conclusions: A comprehensive strategy starting with civilian providers to provide care at the point of wounding along with a coordinated public safety approach to rapidly evacuate the wounded may increase survival in future events.

Tactical Emergency Casualty Care (TECC): Principles and Practice

Tactical Emergency Casualty Care (TECC) is a civilian adaptation of the principles of Tactical Combat Casualty Care (TCCC). It takes into account the tactical environment and objectives and balances priorities in a risk-benefit strategy in order to provide goals of care that are feasible. TECC also takes into account providers ranging from civilian bystanders to fully trained surgeons and their various scopes of practice to render recommendations at various phases of care. The importance of hemorrhage control is stressed, but other causes of potentially preventable death such as pneumothorax and loss of airway are also addressed. Care is divided into Hot, Warm, and Cold Zones with specific objectives and interventions geared to minimize risk to the provider while maximizing patient benefit. Ultimately, the biggest opportunity to mitigate preventable death remains the rapid evacuation of wounded to appropriate definitive care facilities.