Fort Hood shooting - Special Operations Medical Association

Fort Hood shooting - Special Operations Medical Association

Fort Hood shooting - Special Operations Medical Association

6/29/2018 Copyright 2018: Threat Suppression, Inc 1 Best Practice Medical Care at Active Shooter/Hostile Events Presented by: Mike Clumpner, PhD, MBA, NRP © 2018 Disclaimer • The views and opinions discussed in this presentation are those of Threat Suppression, Incorporated and may not reflect the views and opinions of any of the local, state, or federal taskforces or agencies to which our employees are members • Always follow local policies, procedures, and practices 2

Fort Hood shooting - Special Operations Medical Association

6/29/2018 Copyright 2018: Threat Suppression, Inc 2 © 2018 Outline • Active shooter/hostile events (ASHE) • ASHE medical response • Treatment debates • ALS versus BLS • General considerations • Closing 3 © 2018 4

Fort Hood shooting - Special Operations Medical Association

6/29/2018 Copyright 2018: Threat Suppression, Inc 3 © 2018 ASHE • A review of 100 active shooter events in the United States found the following: – Death/serious injury occurs every 15 seconds after the event starts1,2 5 1Police Executive Research Forum. (2014). Critical issues in policing series: Police response to active shooter incidents. Washington, D.C.: Same. 2Peppers, S. (2010). The strategic citizen: A physical security model for strategic critical infrastructure protection. Journal of Physical Security 4(1):10-21.

© 2018 ASHE • 10/16/91: Killeen, Texas – 50 people shot in 12 minutes1 (One person shot every 22 seconds, one person killed every 26 seconds) • 04/16/07: Blacksburg, Virginia – 49 people shot in 10 minutes2 (One person shot every 12 seconds, one person killed every 18 seconds) 6 1Jankowski, P. (2011-October 11). Survivors reflect on October 16, 1991 Luby’s shooting. Killeen Daily Herald. Retrieved from www.kdhnews.com. 2Virginia Tech Review Panel. (2007-April). Mass shootings at Virginia Tech: Report of the review panel presented to Governor Kaine, Commonwealth of Virginia. Blacksburg, VA: Virginia Tech Review Panel.

Fort Hood shooting - Special Operations Medical Association

6/29/2018 Copyright 2018: Threat Suppression, Inc 4 © 2018 ASHE • 07/20/12: Aurora, Colorado – 70 people shot in 90 seconds1 (One person shot every 1.2 seconds, one person killed every 3.75 seconds) • 12/14/14: Newtown, Connecticut – 26 people killed in two minutes and 40 seconds2 (One person killed every 16 seconds) 7 1Tri-Data. (2014). Aurora Century 21 Theater Shooting: Official after action report for the City of Aurora. Arlington, VA: Tri-Data Corporation. 2Staff. (2012). Sandy Hook shooting: What happened? CNN. Retrieved from www.cnn.com. © 2018 ASHE • 12/02/15: San Bernardino, California – 36 people shot in three minutes1 (One person shot every five seconds, one person killed every 12 seconds) • 09/19/16: Orlando, Florida – 107 people shot in 18 minutes2 (One person shot every 10 seconds, one person killed every 20 seconds) 8 1Braziel, R., Straub, F. Watson, G. & Hoops, R. (2016). Bringing calm to chaos: A critical incident review of the December 2, 2015 terrorist shooting incident at Inland Regional Medical Center. Washington, D.C.: U.S. Department of Justice.

2Lotan, G. Minshew, C., Lafferty, M. & Gibson, A. (2017-May 31). Orlando nightclub shooting timeline: Four hours of terror unfold. Orlando Sentinel. Retrieved from www.orlandosentinel.com.

Fort Hood shooting - Special Operations Medical Association

6/29/2018 Copyright 2018: Threat Suppression, Inc 5 © 2018 ASHE • 07/01/17: Little Rock, Arkansas – 25 people shot in 11 seconds in the Power Ultra Lounge club shooting1 (No fatalities, but multiple critical patients) • 10/01/17: Las Vegas, Nevada – 548 people shot in 10 minutes2 (One person shot every second, one person killed every 10 seconds) 9 1Jones, S. & Hackney, D. (2017). 28 people hurt in Arkansas club shooting, police say. CNN. Retrieved from www.cnn.com. 2Ellis, R. & Chavez, N. (2017-October 13). Las Vegas police again change timeline of mass shooting. CNN. Retrieved from www.cnn.com.

© 2018 ASHE • 02/14/18: Parkland, Florida – 27 people shot in six minutes1 (One person shot every 13 seconds, one person killed every 22 seconds) 10 1Fleshler, D. (2018-February 20). The latest on the Parkland school shooting. Orlando Sun Sentinel. Retrieved from www.sun-sentinel.com.

Fort Hood shooting - Special Operations Medical Association

6/29/2018 Copyright 2018: Threat Suppression, Inc 6 © 2018 ASHE • Recognized threats: – Active shooter(s) – Mass stabber(s) – Chemical attacks – Fire-as-a-weapon – Vehicle-as-a-weapon 11 © 2018 ASHE 12

Fort Hood shooting - Special Operations Medical Association

6/29/2018 Copyright 2018: Threat Suppression, Inc 7 © 2018 ASHE 13 © 2018 ASHE 14 “The new ISIS terror weapon is fire. This is an option for anyone wishing to join the terror campaign. With some readily accessible items, one can terrorize a nation.”1 Rumiyah, Issue 5. (2016). Just terror tactics.

Fort Hood shooting - Special Operations Medical Association

6/29/2018 Copyright 2018: Threat Suppression, Inc 8 © 2018 ASHE 15 Inspire Magazine 2011, Issue 2 © 2018 16

Fort Hood shooting - Special Operations Medical Association

6/29/2018 Copyright 2018: Threat Suppression, Inc 9 © 2018 17 Location Date Dead Injured Las Vegas, Nevada 10/02/2017 59 527 Orlando, Florida 06/12/2016 50 54 Blacksburg, Virginia 04/16/2007 32 18 Newtown, Connecticut 12/14/2012 26 02 Killeen, Texas 10/16/1991 23 24 San Diego, California 07/18/1984 21 19 Parkland, Florida 02/14/2018 17 07 Austin, Texas 08/01/1966 15 32 San Bernardino, California 12/02/2015 14 22 Edmund, Oklahoma 08/20/1986 14 06 Binghamton, New York 04/03/2009 13 04 Camden, New Jersey 09/06/1949 13 03 Wilkes-Barre, Pennsylvania 09/25/1982 13 01 Aurora, Colorado 07/20/2012 12 70 = 50 = 28 = 40 = 47 = 24 = 20 = 17 = 16 = 14 = 82 = 47 = 104 CNN Library (2014-Apr 6). VirginiaTech shooting fast facts. Cable News Network. Retrieved from www.cnn.com Johnson, M.A. & Bratu, B. (2012-Dec 17). Police: Second person injured in Connecticut school shooting survived. NCB News. Retrieved from www.nbcnews.com. Kelly, R.L. (2010-Mar). EMS revisited: October 1991 Luby’s shooting. EMS World. Retrieved from www.emsworld.com. Bosh, S. (2014-Jul 18). Survivors recount San Ysidro McDonald’s massacre after 30 years. KUSI San Diego News. Retrieved from www.kusi.com. Hlavaty, C. (2013-Aug 1). 47 years later, Whitman’s tower shooting still a haunting memory for Texans. The Chronicle. Retrieved from www.chron.com. Lamar, J.V. (2001-Jun 24). “Crazy Pat’s” revenge. Time Magazine.Retrieved from www.time.com. Staff. (2009-Nov 5). Gunman kills 12, wounds 31 at Fort Hood. NBC News. Retrievedfrom www.nbcnews.com. McFadden, R.D. (2009-Apr 3). 13 shot dead during a class on citizenship. The New York Times. Retrieved from www.nytimes.com. Goldstein, R. (2009-Oct 9). Howard Unruh, 88 dies: Killed 13 of his neighbors in Camden in 1949. The New York Times. Retrieved from www.nytimes.com. Robbins, W. (1982-Sep 27). Wilkes-Barrekillings:Racial pressures cited. The New York Times. Retrieved from www.nytimes.com. Only includes GSWs = 586 = 36 © 2018 Medical Response • Total number of victims at the Aurora Theater shooting1: – 100 injured, 82 transported by EMS • 70 gunshot wounds • Eight people trampled (several required urgent surgery) • Four injured from the CS gas – 12 dead (10 on the scene) 18 This would tax the resources of most metropolitan EMS agencies, and overwhelm most smaller communities- even with extensive mutual aid 1Tri-Data Corporation. (2014). Aurora Century 21 Theater Shooting: Official after action report for the City of Aurora. Arlington, VA: Same.

Fort Hood shooting - Special Operations Medical Association

6/29/2018 Copyright 2018: Threat Suppression, Inc 10 © 2018 Medical Response • LAX (2013) 1 – Five gunshot wounds, one fatality – 400 patients with evacuation injuries, heat emergencies, and other medical emergencies • (77° and sunny) 19 1Board of LAX Airport Commissioners. (2014-March 18). Active shooter incident and airport disruption after action review: Summary list of observations and recommendations from the Board of Airport Commissioners. Los Angeles, CA: Same. 220 © 2018 Medical Response • At the 2015 reported active shooter event at Northlake Mall in Charlotte on Christmas Eve: – Two gunshot wounds (one fatality) – 17 transported by EMS, including the only documented “tactical” baby delivery at an active shooter event 20

6/29/2018 Copyright 2018: Threat Suppression, Inc 11 © 2018 Medical Response • At the 2017 Hollywood International Airport shooting in Ft. Lauderdale, EMS transported 54 patients to the Broward Health Medical Center1: – Six gunshot wounds (five fatalities) – 48 patients transported by EMS with heat emergencies and ancillary medical emergencies • One dog bite to the face • 79° and raining 21 1Stempniak, M. (2017). Florida hospital CEO shares thoughts following Fort Lauderdale Airport shooting. Hospital and Health Network Magazine. Retrieved from www.hhnmag.com.

© 2018 Medical Response • In active shooter events, time is life1 • Half of the victims at an active shooter event will have moderate to severe ballistic injuries2,3 22 1Flynt, B. (2012). Time and lives: Active shooter casualty triage and collection. Kansas City, MO; The Flynt Group. 2Kaplowitz, L., Reece, M., Hershey, J. H., Gilbert, C. M., & Subbarao, I. (2007). Regional health system response to the Virginia Tech mass casualty incident. Disaster Medicine Public Health Preparedness, 1, S1-S9. 3Linkous, D., & Carter, K.F. (2009). Responding to the shootings at Virginia Tech: Planning and preparedness. Journal of Emergency Nursing, 35, 321-325.

6/29/2018 Copyright 2018: Threat Suppression, Inc 12 © 2018 Medical Response • If a victim suffers a major, yet survivable ballistic injury, their odds of mortality increase 2 – 4% every minute until they reach a surgical suite or receive whole blood replacements1-3 23 1Kaplowitz, L., Reece, M., Hershey, J. H., Gilbert, C. M., & Subbarao, I. (2007). Regional health system response to the Virginia Tech mass casualty incident. Disaster Medicine Public Health Preparedness, 1, S1-S9. 2Linkous, D., & Carter, K.F. (2009). Responding to the shootings at Virginia Tech: Planning and preparedness. Journal of Emergency Nursing, 35, 321-325.

3Crandall, M., Sharp, D., Unger, E., Straus, D., Brasel, K., Hsia, R., & Esposito, T. (2013, April). Trauma deserts: Distance from a trauma center, transport times, and mortality from gunshot wounds in Chicago. American Journal of Public Health, 103(6), 1103-1109. © 2018 Medical Response • In combat research, mortality is 67% if a victim with a major ballistic injury does not receive basic care and evacuation within 30 minutes of injury1 – Half of these victims died from bleeding to death1 24 1Strawder, G.S. (2006, 2nd Quarter). The Golden Hour standard: Transforming combat health support. Joint Forces Quarterly, 41, 60-67.

6/29/2018 Copyright 2018: Threat Suppression, Inc 13 © 2018 Medical Response • “20 – 60 – 90 goal” – RTFs operationalized and providing point- of-wounding care within 20 minutes of injury – All patients transported to area hospitals within 60 minutes from injury – All critical patients in surgery within 90 minutes of injury 25 © 2018 Medical Response • At Virginia Tech, there was a mortality rate of 3.8% for patients who received medical care1 – 12 of the 26 patients seen were categorized as moderately critical to critical1 – Once an EMT made contact with the patient, only one of 26 patients died1 26 1Kaplowitz, L., Reece, M., Hershey, J.H., Gilbert, C.M., & Subbarao, I. (2007). Regional health system response to the Virginia Tech mass casualty incident. Disaster Medicine Public Health Preparedness, 1, S1-S9.

6/29/2018 Copyright 2018: Threat Suppression, Inc 14 © 2018 Medical Response • Fort Hood shooting (2009) – If a patient was alive on arrival at the hospital, they lived through the event1 27 1Shepherd, J., Gerdes, C. & Nipper, M. (2011). Are you ready? Lessons learned from the Fort Hood shooting in Texas. Emergency Radiology 18:109-117 © 2018 Medical Response • Boston Marathon bombing (2014) – If a patient was alive on arrival at the hospital, they lived through the event (170 patients)1 28 1American College of Emergency Physicians. (2015). Mass casualty incident fact sheets. Retrieved from www.acep.org.

6/29/2018 Copyright 2018: Threat Suppression, Inc 15 © 2018 Medical Response • San Bernardino, CA (12/02/15)1 – The 22 wounded were all transported to area hospitals in 57 minutes – Every victim that arrived alive at a hospital survived the event 29 1Braziel, R., Straub, F. Watson, G. & Hoops, R. (2016). Bringing calm to chaos: A critical incident review of the December 2, 2015 terrorist shooting incident at Inland Regional Medical Center. Washington, D.C.: U.S. Department of Justice.

© 2018 General Considerations • Las Vegas Route 91 shooting (10/01/17)1 – “Every patient who arrived alive to Las Vegas hospitals lived through the event. Those who died ‘at the hospital’, were already dead on arrival.” • Dr. Deborah Kuhls, Chief of Trauma and Critical Care, UNLV Medical Center 30 1Kuhls, D. (2018-April 27). Debrief of the UNLV hospital response to the Route 91 shooting. Oklahoma City, OK: University of Oklahoma Annual Trauma Conference:

6/29/2018 Copyright 2018: Threat Suppression, Inc 16 © 2018 Medical Response • The concept of triage – In the crisis site, you are either red or dead – Triage is much less informal, and more focused on rapid extraction of the injured – A more formal triage occurs outside – Consider a “mass hemorrhage runner” 31 © 2018 Medical Response • Casualty collection points (CCPs) 32

6/29/2018 Copyright 2018: Threat Suppression, Inc 17 © 2018 Medical Response • Casualty collection point (CCP) considerations – “Trigger number” – Exterior rooms are preferred – Location • At Virginia Tech the CCP was in the stairwells – CCP vs. Ambulance Extraction Point 33 © 2018 Medical Response • Casualty collection point (CCP) considerations – TACEVAC inertia1 • When CCPs are utilized, the time to TACEVAC increases approximately 5 – 20 minutes per patient1 • Implementing CCPs adds another layer of coordination and communication 34 1Clumpner, M. (2015). Analysis of records that represent an active shooter response model utilizing 32 large-scale exercises. Prescott Valley, AZ: Northcentral University.

6/29/2018 Copyright 2018: Threat Suppression, Inc 18 © 2018 Medical Response • The “CCP shuffle”1 – RTFs have established a CCP only to be told by LE to move the CCP • Condensing CCPs • Moving to more secure locations • Moving the CCP to more victims – In one exercise, the CCP (with 5 – 7 victims) relocated three times in 15 minutes 35 1Clumpner, M. (2015). Analysis of records that represent an active shooter response model utilizing 32 large-scale exercises. Prescott Valley, AZ: Northcentral University.

© 2018 Medical Response 1. Fire and EMS must be involved early in the care of patients 2. Staging is no longer acceptable 3. Fire and EMS personnel must be trained in TCCC/TECC 36 Jacobs, L.M. (2014). Joint committee to create a national policy to enhance survivability from a mass casualty shooting event: Hartford Consensus II. Journal of American College of Surgeons 218(3), 476-478.

6/29/2018 Copyright 2018: Threat Suppression, Inc 19 © 2018 Medical Response 4. Patient care centers around external hemorrhage control followed by rapid transport to an operating room 5. All other patient care is secondary and the efficacy must be clearly indicated 37 Jacobs, L.M. (2014). Joint committee to create a national policy to enhance survivability from a mass casualty shooting event: Hartford Consensus II. Journal of American College of Surgeons 218(3), 476-478. © 2018 Medical Response • The following steps are critical to victim survival at active shooter events1: 1. Rapid recognition and control of life- threatening hemorrhage at the point of injury 2. Extraction of patients outside the crisis site 3. Triage of patients and prioritization of transport to those patients with internal bleeding 38 1Fabbri, W. P. (2014, October). When time matters most [Special section]. Journal of Emergency Medical Services, 4-9.

6/29/2018 Copyright 2018: Threat Suppression, Inc 20 © 2018 Medical Response 39 © 2018 Medical Response • The Committee for Tactical Emergency Casualty Care (C-TECC) conducted an 18-month research study analyzing autopsy reports of 139 victims at active shooter events, representing 15% of events from 2012 – 2014 40 1Smith, E.R., Shapiro, G. & Sarani, B. (2016). The profile of wounding in civilian public mass shooting fatalities. Journal of Trauma and Acute Care Surgery. DOI: 10.1097TA.001031

6/29/2018 Copyright 2018: Threat Suppression, Inc 21 © 2018 Medical Response • Distribution of fatal injuries – Head 39% – Chest and upper back 38% – Extremity 10% – Abdomen and lower back 7% 41 1Smith, E.R., Shapiro, G. & Sarani, B. (2016). The profile of wounding in civilian public mass shooting fatalities. Journal of Trauma and Acute Care Surgery. DOI: 10.1097TA.001031 © 2018 Medical Response • 139 fatalities with 371 gunshot wounds • Average of 2.7 gunshot wounds per patient – Range of 1 to 10 42 1Smith, E.R., Shapiro, G. & Sarani, B. (2016). The profile of wounding in civilian public mass shooting fatalities. Journal of Trauma and Acute Care Surgery. DOI: 10.1097TA.001031

6/29/2018 Copyright 2018: Threat Suppression, Inc 22 © 2018 Medical Response • There were no incidences of exsanguinating, peripheral extremity trauma – A tourniquet would not have saved a single person • Potentially survivable wounds center on the head and chest 43 1Smith, E.R., Shapiro, G. & Sarani, B. (2016). The profile of wounding in civilian public mass shooting fatalities. Journal of Trauma and Acute Care Surgery. DOI: 10.1097TA.001031 © 2018 Medical Response • A 2018 retrospective study of the autopsies of 49 fatalities at the Pulse Nightclub found the following1: – Average number of gunshot wounds of 6.9 – 32% of the patients (n=16) had potentially survivable gunshot wounds • 9 torso injuries • 4 extremity injuries • 2 femoral vessel injuries • 2 axilla injuries 44 1Smith, E.R., Shapiro, G. & Sarani, B. (2018). Fatal wounding pattern and causes of potentially preventable death following the Pulse Night Club shooting. Prehospital Emergency Care: Early Online, 1-7

6/29/2018 Copyright 2018: Threat Suppression, Inc 23 © 2018 45 © 2018 Treatment Debates • A 2013 study examined the efficacy of ALS prehospital treatments compared with survivability for 236 penetrating trauma patients at a Level I trauma center1 – No benefit was found with cervical spine immobilization, IV therapy, or prehospital needle thoracostomy1 46 1Seamon, et al. (2013). Prehospital interventions for penetrating trauma victims: A prospective comparison between advanced life support and basic life support. Injury 44(5):634-638

6/29/2018 Copyright 2018: Threat Suppression, Inc 24 © 2018 Treatment Debates • Needle decompression for tension pneumothoraces: – Retrospective review conducted by the Department of Defense and other institutions have found that most tension pneumothoraces develop in 30 – 40+ minutes after injury1 • Very few tension pneumothoraces will develop rapidly (within minutes) 47 1Callaway, D. (2015- Jan 8). Personal correspondence at the North Carolina Active Shooter Work Group. © 2018 Treatment Debates • McPherson, Feigin, and Bellamy (2006) examined the Wound Data and Munitions Effectiveness (WDMET) database for radiographic evidence of tension pneumothoraces in combat fatalities1 48 1McPherson, J.J., Feigin, D.S., Bellamy, R.F. (2006) Prevalence of tension pneumothorax in fatally wounded combat casualties. Journal of Trauma 60(3):573-578

6/29/2018 Copyright 2018: Threat Suppression, Inc 25 © 2018 Treatment Debates • 893 fatalities were examined with readable, radiographic files1 – All casualties had thoracic trauma – Radiographic evidence of tension pneumothoraces with 3 – 4% of the fatalities • Some of the casualties had other fatal conditions, such as trachealbronchial disruption, lacerated tracheal trees, and more 49 1McPherson, J.J., Feigin, D.S., Bellamy, R.F. (2006) Prevalence of tension pneumothorax in fatally wounded combat casualties. Journal of Trauma 60(3):573-578 © 2018 Treatment Debates • A 2006 and 2007 study found that the prevalence of prehospital tension pneumothoraces was grossly exaggerated1 • The study concluded that the prevalence of tension pneumothoraces is 0.3% for patients with penetrating chest trauma and who are awake when a provider makes contact with them1,2 50 1Leigh-Smith, S. (2007). Tension pneumothorax prevalence grossly exaggerated. Emergency Medical Journal, 24(12):865 2McPherson, J.J., Feigin, D.S. & Bellamy, R.F. (2006). Prevalence of tension pneumothorax in fatally wounded combat casualties. Journal of Trauma 60(3):573-578

6/29/2018 Copyright 2018: Threat Suppression, Inc 26 © 2018 51 © 2018 Head-to-Head • In a comprehensive review of 49 large studies, Lieberman and colleagues (2000) reported an odds ratio of death 2.59 times higher when a trauma patient receives ALS care versus BLS care 52 1Lieberman, M., Mulder, D., Sampalis, J. (2000) Advanced or basic life support for trauma: A meta-analysis and critical review of the literature. Journal of Trauma 49(4):584-599

6/29/2018 Copyright 2018: Threat Suppression, Inc 27 © 2018 Head-to-Head • Lieberman and colleagues (2003) examined an urban area served by Level One trauma centers and a two- tiered ALS/BLS system – Trauma patients who received ALS care had a 29% mortality rate* – Trauma patients who received BLS care had a 18% mortality rate* 53 1Lieberman, et al. (2003) Multicenter Canadian study of prehospital trauma care. Ann Surg 273(2): 153-160 *Injury severity score and mortality adjusted © 2018 Head-to-Head • Trauma patient mortality by EMS provider skill level1: – EMT providers: patient mortality of 26% – Paramedic providers: patient mortality of 28% – Physician providers: patient mortality of 32% 54 1Lieberman, et al. (2003). Multicenter Canadian study of prehospital trauma care. Ann Surg, 273 (2): 153-160 Study conclusion: “In urban areas with specialized trauma centers, there is no benefit for having on-site ALS for prehospital trauma patients.”1

6/29/2018 Copyright 2018: Threat Suppression, Inc 28 © 2018 Head-to-Head • For every EMS procedure, there is an average addition of one minute to the total on-scene time1 55 1Carr, B.G., Brachet, T. David, G., Dusei, R. & Branas C.C. (2008). The time cost of prehospital intubation and intravenous access in trauma patients. Prehospital Emergency Care, 12(3):327-332 © 2018 Head-to-Head • Treatment debate – In the urban setting, it may be most beneficial for trauma patients if paramedics maintain a simple airway, not start IV fluids, not conduct advanced skills, and do not delay transport to the hospital1 56 1Smith, R.M., Conn, A, K. (2009) Prehospital care- Scoop and run or stay and play? Injury. 4054:S23-S26

6/29/2018 Copyright 2018: Threat Suppression, Inc 29 © 2018 57 © 2018 Trauma Fluid Resuscitation “If the blood pressure is raised without a surgeon to stop the bleeding, blood will be lost.” – Canon, et al. (1918). Rationale of treatment of toxic and infection psychoses. Journal of the American Medical Association, 71(4):253-257 58

6/29/2018 Copyright 2018: Threat Suppression, Inc 30 © 2018 Trauma Fluid Resuscitation • Approximately 28% of trauma patients arrive to the emergency department with established coagulopathy disorders1,2 – Coagulopathy is associated with early and late mortality1 – Coagulopathy disorder on arrival at the emergency department represents a five- fold increase in mortality3 59 1Gruen, et al. (2012). Hemorrhage control in severely injured patients. Lancet 380:1099-1108 2MacLeod, J.B., Lynn, M., McKenney, M.G., Cohn, S.M., & Murtha, M. (2003). Early coagulopathy predicts mortality in trauma. Journal of Trauma, 55: 39-44 3Brohi, K., Cohen, M.J., & Davenport, R.A. (2007). Acute coagulopathy of trauma: mechanism, identification and effect. Current Opinions in Critical Care, 13: 680-685 © 2018 Trauma Fluid Resuscitation • Prehospital IVs can be particularly difficult in trauma patients, with documented average times to establish between 8 and 12 minutes1 • The average prehospital IV increases scene time by 5 minutes and 4 seconds2,3 60 1Smith, R.M., Conn, A, K. (2009). Prehospital care- Scoop and run or stay and play? Injury. 4054:S23-S26 2Carr, B.G., Brachet, T. David, G., Dusei, R. & Branas C.C. (2008). The time cost of prehospital intubation and intravenous access in trauma patients. Prehospital Emergency Care, 12(3):327-332 3Minville, et al. (2006). Prehospital intravenous line placement assessment in the French emergency system: A prospective study. European Journal of Anesthesiology, 23:594-597

6/29/2018 Copyright 2018: Threat Suppression, Inc 31 © 2018 Trauma Fluid Resuscitation • Attempts at IV access by EMS providers on scene is often greater than the total transport time1-3 61 1Smith, J.P., Bodai, B.I., Hill, A.S. & Frey, C.F. (1985). Prehospital stabilization of critically injured patients: A failed concept. Journal of Trauma, 25:65-70. 2Sampalis, et al. (1997). Ineffectiveness of on-site intravenous lines: Is prehospital time the culprit? Journal of Trauma, 43:608-614 3Seamon, et al. (2007). Prehospital procedures before emergency department thoracotomy: “Scoop and Run” saves lives. Journal of Trauma-Injury Infection and Critical Care, 63(1):113-120 © 2018 Trauma Fluid Resuscitation • In 2009, the Eastern Association for the Surgery of Trauma reviewed all available literature that focused on prehospital vascular access and fluid resuscitation of trauma patients written in the English language and published between 1982 and 20071 – The study evaluated 3,392 research articles 62 1Cotton, et al. (2009). Eastern Association for the Surgery of Trauma Practice Parameter Workgroup for Prehospital Fluid Resuscitation guidelines for prehospital fluid resuscitation in the injured patient. Journal of Trauma, 67(2), 389-402.

6/29/2018 Copyright 2018: Threat Suppression, Inc 32 © 2018 Trauma Fluid Resuscitation • The researchers made the following conclusions after reviewing the research1: – There is insufficient data to recommend the placement of vascular access by EMS providers in trauma patients – Vascular access should never be attempted on scene at the cost of delaying the arrival of the patient to the hospital 63 1Cotton, et al. (2009). Prehospital fluid resuscitation in the injured patient. Journal of Trauma, 67(2):389-402. © 2018 Trauma Fluid Resuscitation • The researchers made the following overall conclusion after reviewing all of the published literature1: – There is insufficient scholastic data to show that trauma patients benefit from prehospital fluid resuscitation 64 1Cotton, et al. (2009). Prehospital fluid resuscitation in the injured patient. Journal of Trauma, 67(2):389-402.

6/29/2018 Copyright 2018: Threat Suppression, Inc 33 © 2018 Trauma Fluid Resuscitation “Giving IV fluids to patients before they go to the hospital can delay transport. Our study suggests it may be better to get patients to the hospital faster. Starting fluids takes time and the IV fluids may cause harm on top of the delay in transport.”1 -Elliott R. Haut, M.D. Associate Professor of Surgery, Anesthesiology, and Critical Care Medicine: Johns Hopkins University School of Medicine 65 1Kalish, et al. (2011). On scene IV fluids for trauma patients: Life saver or time waster? Baltimore, MD: John Hopkins University School of Medicine.

© 2018 66

6/29/2018 Copyright 2018: Threat Suppression, Inc 34 © 2018 Trauma Transport • A study was conducted analyzing data from the American College of Surgeons National Trauma Databank for admission years 2007 through 20101 – A total of 2,539,818 incidents were analyzed with 74,187 adult patients (16+) with gunshot wounds admitted to 182 U.S. trauma centers 67 1Zafar, S. N., Haider, A. H., Stevens, K. A., Ray-Mazumder, N., Kisat, M. T., Schneider, E. B . Haut, E. R. (2014). Increased mortality associated with EMS transport of gunshot wound victims when compared to private vehicle transport. Injury, 45, 1320-1326.

© 2018 Trauma Transport • Bivariate logistic regression analysis was conducted to determine a correlation between mortality and mode of transport (EMS vs. POV)1 – Analysis revealed that GSW patients were twice as likely to die when transported by EMS than POV1 68 1Zafar, S. N., Haider, A. H., Stevens, K. A., Ray-Mazumder, N., Kisat, M. T., Schneider, E. B . Haut, E. R. (2014). Increased mortality associated with EMS transport of gunshot wound victims when compared to private vehicle transport. Injury, 45, 1320-1326.

6/29/2018 Copyright 2018: Threat Suppression, Inc 35 © 2018 Trauma Transport • Patients transported by POV were in much earlier stages of shock than those patients transported by EMS1 – The researchers attribute delays in on- scene time by EMS and attempts at medical procedures that are not beneficial to the patient as the leading cause of decreased survivability in penetrating trauma patients transported by EMS1 69 1Zafar, S. N., Haider, A. H., Stevens, K. A., Ray-Mazumder, N., Kisat, M. T., Schneider, E. B . Haut, E. R. (2014). Increased mortality associated with EMS transport of gunshot wound victims when compared to private vehicle transport. Injury, 45, 1320-1326.

© 2018 Trauma Transport • Retrospective review of penetrating trauma patients transported by EMS1 – Every prehospital procedure performed is an individual predictor of increased mortality – Conclusion: The performance of prehospital procedures in critical penetrating trauma patients directly decreases survivability. Paramedics should stick to “scoop and run” 70 1Seamon, et al. (2007). Prehospital procedures before emergency department thoracotomy: “Scoop and Run” saves lives. Journal of Trauma-Injury Infection and Critical Care, 63(1):113-120

6/29/2018 Copyright 2018: Threat Suppression, Inc 36 © 2018 Trauma Transport • A 2017 study looked at 103,000 patients with penetrating trauma transported to U.S. trauma centers1 – The researchers concluded that the odds of death increases five times for patients transported by ambulance than those transported in privately owned vehicles – The researchers attribute attempts at unnecessary treatment on scene (IV, intubation, spinal immobilization) as the leading cause of increased mortality 71 1Wandling, M.W., Nathens, A.B., Shapiro, M.B., et al. (2017). Association of prehospital mode of transport with mortality in penetrating trauma. Journal of the American Medical Association Surgery. doi:10.1001/jamasurg.2017.3601 © 2018 Trauma Transport • A study conducted in Iraq found that paramedic-level care increased survivability for trauma patients, when transport time exceeded two hours1 – N= 2,788 – 37% of patients had an ISS ≥9 – Mean transport time was 2.5 hours – Mortality decreased from 17% to 4% 72 1Murad, M.K., Larsen, S. & Husum, H. (2012). Prehospital trauma care reduces mortality: Ten-year results from a time cohort and trauma audit study in Iraq. Scandinavian Journal of Trauma Resuscitation and Emergency Medicine, 20:13

6/29/2018 Copyright 2018: Threat Suppression, Inc 37 © 2018 Trauma Transport • At the February 2017 Gathering of the Eagles Conference in Dallas, medical directors from the nation’s 35 largest cities met to discuss hot topics in EMS1 – At the meeting, numerous medical directors agreed that transporting patients in police cars can be very beneficial to reducing mortality1 73 1Gates, H. (2017- June 26). Gathering of the Eagles Part II: Responding to active shooter events. EMS World. Retrieved from www.emsworld.com.

© 2018 Trauma Transport “Grabbing a victim and throwing them in the back of a police car may be heresy to some, but police can drive really fast. What these victims really need is an operating room.”1 – Dr. Jeffrey Metzger, Medical Director for Dallas Police Department and Dr. Kenneth Scheppke, Medical Director for Palm Beach County Florida 74 1Gates, H. (2017- June 26). Gathering of the Eagles Part II: Responding to active shooter events. EMS World. Retrieved from www.emsworld.com.

6/29/2018 Copyright 2018: Threat Suppression, Inc 38 © 2018 75 “No patient should die on scene awaiting an ambulance.”1 1Clumpner, M., Vernon, A., Tanner, T., Bachman, M., Jeffries, D. & Groves, J. (2017). White paper for the integrated public safety response to the active shooter/active assailant. Raleigh, NC: State of North Carolina. Trauma Transport © 2018 76

6/29/2018 Copyright 2018: Threat Suppression, Inc 39 © 2018 General Considerations • Las Vegas Route 91 shooting (10/01/17)1 – 60 minutes into the event, every single police, fire, and EMS unit in Clark County was dedicated to the incident – At the 60-minute mark, there were 68 gunshot calls holding in a five-mile radius from Mandalay Bay 77 1Cassell, G. & Clark, J. (2017-November 7). Debrief of the Las Vegas Route 91 shooting. San Marcos, TX: ALERRT Active Shooter Conference © 2018 General Considerations • Las Vegas Route 91 shooting (10/01/17)1 – “You may think that you will only train specialized units in your fire department to respond to active shooter events. Within 20 minutes, every on-duty firefighter and paramedic with Las Vegas Fire Department, Henderson Fire Department, and Clark County Fire Department was responding to this event.” 78 1Cassell, G. & Clark, J. (2017-November 7). Debrief of the Las Vegas Route 91 shooting. San Marcos, TX: ALERRT Active Shooter Conference

6/29/2018 Copyright 2018: Threat Suppression, Inc 40 © 2018 General Considerations • Las Vegas Route 91 shooting (10/01/17)1 – Las Vegas Fire Department • 21 stations – Clark County Fire Department • 42 stations (29 career) – North Las Vegas Fire Department • 8 stations – Henderson Fire Department • 10 stations 79 1Cassell, G. & Clark, J. (2017-November 7). Debrief of the Las Vegas Route 91 shooting. San Marcos, TX: ALERRT Active Shooter Conference 68 career fire stations and 550+ on-duty fire/EMS personnel were assigned to the shooting in the first 60 minutes © 2018 General Considerations • Las Vegas Route 91 shooting (10/01/17)1 – “Multiple ‘cold zones’ immediately became ‘hot zones’, as this incident rapidly spread out more than five square miles in a metropolitan, downtown area.” 80 1Cassell, G. & Clark, J. (2017-November 7). Debrief of the Las Vegas Route 91 shooting. San Marcos, TX: ALERRT Active Shooter Conference

6/29/2018 Copyright 2018: Threat Suppression, Inc 41 © 2018 General Considerations • Las Vegas Route 91 shooting (10/01/17)1 – 80% of the patients self-transported to area hospitals – 639 people were treated at Las Vegas area hospitals – Patients also self-transported to hospitals in California, Texas, Utah, and Arizona 81 1Kuhls, D. (2018-April 27). Debrief of the UNLV hospital response to the Route 91 shooting. Oklahoma City, OK: University of Oklahoma Annual Trauma Conference. © 2018 General Considerations 82

6/29/2018 Copyright 2018: Threat Suppression, Inc 42 © 2018 83 © 2018 84

6/29/2018 Copyright 2018: Threat Suppression, Inc 43 © 2018 Closing “The Hollywood International Airport shooting revealed weaknesses and unfamiliarity with many involved. The ability to navigate in the 21st Century requires abandonment of antiquated mindsets. To move forward, distinct operational paradigm shifts must be acknowledged and embraced.”1 -Major Angelo Cedeno, Broward County Sheriff’s Office 85 1Cedeno, A., Furman, R., Torres, V., & Diefenbacher, J. (2017). Fort Lauderdale-Hollywood International Airport active shooter/mass evacuation and its impact upon airport operations. Fort Lauderdale, FL: Broward County Sheriff’s Office.

© 2018 Closing “When you entered into public safety, you accomplished your greatest act of bravery. Everything else is simply in the line of duty. Your efforts will never exceed the expectations of this job. You either meet the expectations, or you fail. You became a hero the day you put the uniform on. Your actions at work do not make you a hero; you are doing exactly what this business requires.”1 - FDNY Chief Edward Croker (1906) 86 1Adapted from FDNY Chief Edward Crocker’s speech at the funeral of five FDNY firefighters in February, 1906. Retrieved from www.firemuseumnetwork.org.

6/29/2018 Copyright 2018: Threat Suppression, Inc 44 Contact Information Twitter @ThreatSuppress www.ThreatSuppression.com 1.800.231.9106 Facebook.com/ThreatSuppression info@ThreatSuppression.com

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