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New 'Active Shooter' Protocol: Despite Danger, Stop The Bleeding Faster

Emergency responders comfort a woman on a stretcher who was injured in one of the blasts near the Boston Marathon finish line. (Jeremy Pavia/AP)
Emergency responders comfort a woman on a stretcher who was injured in one of the blasts near the Boston Marathon finish line. (Jeremy Pavia/AP)

In any mass attack on the public — whether gun or bomb, mall or marathon — the first priority is to stop the killing. Typically, medical care tends to be delayed until danger is past. But that is now changing, to more of an emphasis on also stopping the victims' bleeding — faster.

In the wake of the Sandy Hook Elementary School shooting nearly a year ago, a group of medical, military and law enforcement experts, commissioned by the American College of Surgeons, convened to answer a burning question: How do you increase survival in such mass attacks?

That "Hartford Consensus" group issued its initial concept document just 10 days before the Boston Marathon bombings in April, said Dr. Lenworth Jacobs, a trauma surgeon at Hartford Hospital. The much-admired emergency response to the marathon attack only bolstered the group's findings. Support grew, and federal authorities — Homeland Security and FEMA — adopted the Hartford-based protocols in September, he said.

'You get that timer in your head: If there are people alive...you've just really got to speed things up.'

Dr. Jacobs appears on Radio Boston today, and explains what the new guidelines say. The background:

In an attack, he said, "There are three zones. There's the hot zone, which is actually dangerous, there's an active shooter there, and the whole concept is to suppress that threat. However, in the warm zone, which is usually pretty close to the hot zone but it's out of the sight of the shooter, there, you want to be controlling the hemorrhage. And classically, those have been different things. Law enforcement people have gone to suppress the shooter but have not necessarily been involved in controlling the hemorrhage. Now you want to have them, and the medical and rescue service people, involved very quickly in controlling hemorrhage. And then in the cold zone, which is safe, you need to do a full assessment of that person and then transport them to hospital.

What has happened is that these have been three very separate zones with three different kinds of people in there. What we're proposing is that those zones should be compressed. So yes, you will have a hot zone but almost overlapping is the warm zone and overlapping that is the cold zone. So that the care is done much more quickly."

The new guidelines don't mean paramedics join SWAT teams, Dr. Jacobs explained; rather, they mean that "the first responder — police and threat suppression — also has, as part of their mission, if somebody is actively bleeding to death, to stop that bleeding. The second part is, you'd like to get the care part — whether paramedics or EMTs — to take care of them very quickly....you'd have the hemorrhage stopped very quickly, patient fully assessed and then transported very quickly."

Boston had already been heading in this direction, said James Hooley, chief of Boston's Emergency Medical Services, and he's in general agreement with the new guidelines.

"I'm glad to see that there is some formal guidance coming out on this," he said, "because it was an area that we have really tried to make some inroads in ourselves for the last couple of years."

"We started working — with the Boston Police Department obviously taking the lead — they recognized way back after Columbine that they needed ways to more effectively contain and locate the shooter or the threat — that was their focus for many years, to make the scene safe," he said. "The follow-on, however, was if there were patients who are alive, who have survivable injuries, we want to be able to get in, care for them and extract them as quickly as we can. Knowing that in the case of some active shooter scenarios, we may not have 100 percent guarantee that the scene is safe."

It's not unlike the risk after a bomb, he said, that the bomber may have planted a secondary device aimed at rescuers. Boston EMS has worked on drills with police, including the use of armored police vehicles to ferry medics in and patients out of attack scenes.

"Ultimately," he said, "You get that timer in your head: If there are people alive, people with survivable injuries, if we can get them out in time and effectively care for then, you've just really got to speed things up."

Further reading: Medical Staff Preps For Code Silver, Or Active Shooter In The Hospital

In Mass Attacks, New Advice Lets Medics Rush In

This program aired on December 9, 2013. The audio for this program is not available.

Carey Goldberg Twitter Editor, CommonHealth
Carey Goldberg is the editor of WBUR's CommonHealth blog.

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