have been characterized by the Hartford Consensus
group. The basic essential skills that we recommend
to the public for active shooter events will also prove
to be essential for other catastrophic all-hazards events
facing our nation.
Skills needed for immediate responders
to an active shooter event
The skills needed by a civilian immediate responder
are simple but need to be executed in a complex,
evolving, and sometimes unsecure environment.
The immediate responder first should understand
the threat of the active shooter and how law enforcement will tactically try to eliminate that threat.
Immediate responders must be aware of their own
safety and that of the injured. Without a thorough
understanding, the immediate responder could
become a liability or, worse, yet another casualty.
First and foremost, the immediate responder must
listen to direction from professional first responders as they arrive on scene.
The goal of the immediate responder is to stop
exsanguinating hemorrhage by the simplest methods available, beginning with direct pressure and
including the use of tourniquets when needed.
The patient should be moved as soon as possible
to a place of relative safety so as to prevent further injury.
The immediate responder, as soon as feasible,
should notify professional emergency medical services responders so an assessment of the patient and
first responder care rendered can be done, adequate
triage can begin, and transport to definitive care
can be prioritized. These steps are summarized in
the Hartford Consensus THREAT acronym: T hreat
suppression, Hemorrhage control, Rapid E
xtrication to safety, Assessment by medical providers,
and Transport to definitive care.
Educational theory, perishable skills,
competency, and certification issues
A large body of academic information exists regarding educational methods and how best to retain
perishable skills so that they will be clinically effective. We also have decades of precedent with the Red
Cross’ and American Heart Association’s cardiopulmonary resuscitation (CPR) training and retraining
of civilians. One of the most important variables in
preventing death from out-of-hospital cardiac arrest
has been clearly demonstrated to be well-trained
immediate responders who have had CPR training
and immediately institute CPR as bystanders. If not
for this critical link, definitive cardiac care would
not be effective, and lives would be lost. An analogy can be made with the immediate responders’
stopping exsanguinating hemorrhage to stabilize
a patient in preparation for lifesaving definitive
As the public becomes engaged and is educated and
trained in how to stop exsanguinating hemorrhage,
we must ensure that there is continuing education
and training to prevent these essential skills from
perishing, because immediate responders may never
actually use these skills in a crisis. First responders
with this knowledge are a critical link in our survival
chain and must always be prepared, just like individuals trained in CPR.
Periodical assessment of competency in the hemorrhage control skills needed is also essential not
only for ensuring that quality care is being rendered, but also to make sure that the Department
of Homeland Security fully understands and categorizes this immediate responder asset in our
national response framework. The issue of how
best to ensure the currency and competency of all
immediate responders requires more discussion by
our thought leaders in this area.
It is now apparent that we must educate and train members
of the American public to ensure that they know how
to protect themselves and how to act immediately and
independently during the active shooter events that have
been characterized by the Hartford Consensus group.