The Hartford Consensus: How to Maximize Survivability in Active Shooter and Intentional Mass Casualty Events

The recent events at the Boston Marathon bombings, the bombing at the shopping mall in Nairobi, Kenya, and the shootings at the Navy Yard in Washington, DC continue to make it clear that active shooter and intentional mass casualty incidents require comprehensive responses to increase survival and minimize disabilities. The Joint Committee to Create a National Policy to Enhance Survivability from Mass Casualty Shooting Events was formed to identify the needed changes to improve survival. It was initiated by the American College of Surgeons (ACS) in an effort to ensure that victims receive expeditious treatment of their injuries. On 2 April and 11 July 2013, a group of select representatives from national public safety organizations that included health, law enforcement, fire, prehospital care, trauma care, and the military met in Hartford, Connecticut, USA to suggest strategies to increase survivability from active shooter and intentional mass casualty events. The concepts supported by both meetings have become known as the Hartford Consensus [1, 2]. The overarching principle of the Hartford Consensus is that the current response and management of these events needs to change. Lessons learned from previous events make this clear. An analysis of the emergency medical response at Columbine High School in Colorado revealed that there was significant delay and some victims may have died waiting for medical treatment [3]. More recently, at the Los Angeles Airport shooting on 1 November 2013, an officer was wounded and left unattended for 33 min even though for most of that time there was no threat from the suspected gunman [4]. The officer had no signs of life upon arrival at the medical center and was unable to be revived. Delays such as these are not acceptable. There are several reasons for the delay in attending to victims. The response to events is hindered by the lack of a unified command structure and common language of the various responding groups. Because these events typically happen in a very short time, any delay in formulating a coordinated response can mean the difference between life or death for the victims. Traditionally, responding police officers have focused on suppressing the shooter. Until that is accomplished, treating victims is a secondary objective. Providing hemorrhage control has not been one of their responsibilities. The desire to provide a safe environment for emergency medical services (EMS) has prevented access to victims until law enforcement grants them access. This philosophy has resulted in medical responders waiting at the perimeter of the event. Law enforcement in the past has focused on management of the crime scene and collecting and preserving evidence to the detriment of victim survival. The Hartford Consensus has declared that these response issues must be eliminated and the expeditious attention to victim survival is a priority. The Hartford Consensus produced two documents [1, 2]. The first describes the fundamental concepts to increase survival and the second is a call to action. The call to action is that no one should die from uncontrolled bleeding. An acronym summarizes the needed response: THREAT (T indicates threat suppression, H for hemorrhage control, RE for rapid extrication of the victims from the scene, A for assessment by medical providers, and T for transport to definitive care). Although responders may include the public, law enforcement, EMS/fire/rescue, and definitive trauma care, hemorrhage control must be seen as a core law enforcement responsibility. L. Jacobs (&) Academic Affairs, Hartford Hospital, Hartford, CT, USA e-mail: lenworth.jacobs@hhchealth.org