Editor’s note: The Joint Committee to Create a National
Policy to Enhance Survivability from Intentional Mass Casualty and Active Shooter Events developed the following
call to action at its January 7–8 meeting in Dallas, TX. This
committee meeting, chaired by American College of Surgeons (ACS) Regent Lenworth M. Jacobs, Jr., MD, MPH, FACS,
focused on the implementation of strategies to empower
bystanders to help victims of mass casualty events. The
following is the Hartford Consensus IV, edited to conform
with Bulletin style.
Despite advances in the response to active shooter and intentional mass casualty events, a gap remains in our national preparedness
and resilience. Drawing from experiences at myriad
mass casualty events, the immediate responder
(volunteer responder) represents an underutilized
resource, yet one capable of dramatically increasing
our all-hazards (injuries from all natural and man-made causes) national resilience. The overarching
principle of the Hartford Consensus, outlined in
previous reports, is that no one should die from
uncontrolled bleeding. We have championed the
following acronym to summarize what we have
determined are appropriate steps to ensure that the
maximum number of victims of these tragic events
can be saved:
THREAT:
• Threat suppression
•Hemorrhage control
•Rapid Extrication to safety
•Assessment by medical providers
• Transport to definitive care
Status update
Continuing in our efforts to improve survival from
these events and the more common traumatic injuries
that occur daily in the U.S., the Hartford Consensus
met for the fourth time in January. The discussion at
this meeting was focused on the role of individuals in
immediate proximity to victims of injury, whatever
the etiology.
Based on foundational work by the U.S. Department
of Defense and the Committee on Tactical Combat
Casualty Care (CoTCCC), previous Hartford Consensus reports have centered on improvements in
the professional responder’s role in providing care to
individuals wounded in active shooter and intentional
mass casualty events. We submit that harnessing the
power of immediate responders is not a new concept,
as the public has been used to successfully initiate car-diopulmonary resuscitation (CPR) in the event of an
out-of-hospital cardiac arrest. Furthermore, seminal
work describing the lifesaving benefit of TCCC training in maximizing casualty survival among our troops
wounded in combat in Iraq and Afghanistan has uniformly emphasized the importance of all personnel
in dangerous environments, not just medics, being
trained and equipped to control external hemorrhage
when their unit members are injured (also known as
Buddy Care). Because the public, by and large, has the
will to help in these situations, this report seeks to
outline the next steps necessary to continue to fortify
our national resilience for a public response to hemorrhage control.
To date, the professional first responder community, including emergency medical services (EMS), law
enforcement officers, fire and rescue personnel, and
public safety officials, have widely accepted the Hartford Consensus’ principles. For example, the concept of
immediate Threat suppression, which maximizes survival from life-threatening injuries, has been embraced
and implemented on a national level.
External Hemorrhage control is the intervention that has proven most effective in the prehospital
setting. The victim, an immediate responder, or a professional first responder should use this technique as
quickly as possible once the immediate threat of further injury has been mitigated.
The concept of Rapid Extrication of casualties
from areas of direct threat (hot zones) to less dangerous but not completely secure areas (warm zones) or
secure areas (cold zones) expedites Assessment and
Transport to definitive care. Furthermore, casualties
no longer are expected to remain untreated for significant periods of time until the area is completely secure.
The overarching principle of the Hartford Consensus,
outlined in previous reports, is that no one should die
from uncontrolled bleeding.
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