Pre-Hospital Care in Mass Casualty Shootings–An Update

Update:

In September of 2019, shortly after my post below, Capt. Brad Bennett published an update for the Committee on Tactical Combat Casualty Care (CoTCCC) in the WMS magazine article titled, “Committee on Combat Casualty Care Updates and Expands Recommended Tourniquet List”. I wanted to repost my article with some updates and add a link to Capt. Bennett’s paper along with some links to the tourniquets themselves (Disclaimer: I do earn a commission for any sales at no cost to the consumer). He points out in the article that there has been a dearth of research about the effectiveness of tourniquets available on the market and that this update, 15 years in the making, seeks to rectify that situation. They are evaluating 19 of the 1,627 devices currently approved by the FDA for use as a tourniquet. In the near future, the study results should be concluded and published in the Journal of Special Operations Medicine. I will be sure to post those results once available.

Original Article:

You will likely recognize the above picture as a CAT tourniquet. As programs such as Stop The Bleed and others have focused on the use of tourniquets in the field, these have become a popular item for most to carry in our kits. This is for good reason too. Studies and data coming from military experience in Afghanistan and Iraq have shown, these devices are no longer to be considered the “last ditch” efforts we once thought. That being said, what does the data show about efficacy or applicability of this data in civilian shootings as we have recently seen in El Paso and Dayton?

This very question was addressed in the May/June 2019 edition of the Air Medical Journal. Three studies by Smith, Butler and de Jager were used to discuss differences between the battlefield and civilian injuries. Interestingly, military injuries tend to be to extremities. This is due to several reasons. First, many soldiers are injured by high explosive devices and the fragments coming off of them. Secondly, the battlefield and the highly armed nature of the two sides on the battlefield, tends to separate the combatants much further than what is seen in the civil setting. This separation makes shots to vital areas such as the torso, head and neck less likely. Finally, soldiers tend to wear body armor that covers vital areas. While not fool proof, especially against higher caliber and more powerful rounds, it can protect against many rounds, especially if shot from a distance.

What does this difference mean for civilian first responders in such scenarios? It means that chest, back and head shots are much more likely. These areas are, obviously, not amenable to tourniquet placement. So, while still important, we need to adjust training and prepare our first responders for what they are more likely to see. In particular, the authors advise focusing on chest wounds. While there are many who have survived head shots, the chest can be far more survivable. Focusing on pressure and hemostatic impregnated gauze as well as chest seals and decompression may be the next line in pre-Hospital treatment. Also, ensuring such first responders are well versed in all forms of artificial airways can be lifesaving.

Whether you are an EMT, Paramedic, nurse, doctor or private civilian, many of these techniques can be learned and practiced in courses offered throughout the country. Keep your tourniquets on hand but be ready with even more advanced skills should you be unfortunate enough to find yourself in a situation where you need to employ them.

DISCLAIMER: THIS CONTENT DOES NOT PROVIDE MEDICAL ADVICE.  The information contained herein or provided to you is for informational purposes only. It is not intended to be professional medical advice, diagnosis or treatment.  It has not been developed based on your specific medical history or condition or as a result of any medical evaluation.  It may not cover all possible health care conditions, drug interactions or governmental warnings or alerts. You should not rely on this information as an endorsement of any specific tests, physicians, products, procedures, opinions, or other information. None of the information is intended to be a substitute for professional medical advice, diagnosis or treatment.  You should always check with your physician if you have health questions or concerns. The CDC also provides a comprehensive list of CDC travel warnings. Although we attempt to provide accurate and up-to-date information, no guarantee is made to that effect.

References:

1. Air Medical Journal, May/June 2019; p. 137-138.

2. Smith ER, Shapiro G, Sarani B. The profile of wounding in civilian public mass shooting fatalities. J Trauma Acute Car Care Surg, 2016; 81:86-92.

3. Butler FK. Military history of increasing survival: the U.S. military experience with tourniquets and hemostatic dressings in the Afghanistan and Iraq conflicts. Bull Am Coll Surg, 2015; 100: 60-64.

4. de Jager E, Goralnick E, McCarty JC, et al. Lethality of civilian active shooter incidents with and without semiautomatic rifles in the United States. JAMA. 2018; 320; 1034-1035.

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