In recent years, civilian law enforcement officers and EMS responders have been called to bombing incidents, school and mall shootings, and other terror attacks that present tactical situations similar in some respects to those encountered on battlefields. The threat of ongoing hostile fire, treating multiple casualties under cover, and prolonged evacuation times have all come into play. Even in urban settings, getting to, treating, and transporting casualties can require tactics and training outside the parameters of many standard EMS protocols. The mass casualty incidents at Columbine High School, Virginia Tech, and Sandy Hook Elementary School are examples in point. More widespread adoption of applicable TCCC guidelines into tactical EMS training programs, and application of these principles to tactical law enforcement operations may result in better tactical flow and additional lives saved.

The individual most responsible for helping to facilitate the translation of the military success with tourniquets and hemostatic dressings to the civilian sector is Hartford, Connecticut, trauma surgeon Lenworth Jacobs. In 2013, Dr. Jacobs convened the Hartford Consensus working group (the formal name of the group was the “Joint Committee to Create a National Policy to Enhance Survivability from Active Shooter and Intentional Mass Casualty Events.”) With Dr. Jacob’s advocacy, the Hartford Consensus was chartered by the American College of Surgeons (ACS) to identify measures that would help to improve survival for the victims of mass casualty incidents. He undertook this effort after the governor of Connecticut asked for his assistance in reviewing the tragic deaths in the Sandy Hook shootings and making recommendations about what measures might be undertaken to improve survival in future mass shooting incidents. Dr. Jacobs convinced the leadership of the ACS that the College should strongly advocate for improving the prehospital care for the victims of these incidents, primarily through the first responder use of tourniquets and hemostatic dressings to control external hemorrhage.

The Hartford Consensus Group included representatives from the White House, the Department of Defense, the Department of Homeland Security, and the ACS. The participants included national leaders in trauma surgery, Dr. Jacobs, the late Dr Norman McSwain (trauma director at the Spirit of Charity Hospital in New Orleans), Dr. Richard Carmona (former Surgeon General of the United States), Dr John Holcomb (the driving force behind many of the Department of Defense’s advances in trauma care during the recent conflicts), Dr. Frank Butler (Chair of the DoD’s Committee on TCCC), and Dr Ronnie Stewart (Chair of the ACS Committee on Trauma). Also included were leaders from law enforcement agencies (Drs. Dave Wade and Bill Fabbri from the FBI and Dr. Alex Eastman, from Dallas SWAT) as well as fire service agencies. The Hartford Consensus Group held a series of three meetings in 2013–2015 and published three advisory statements, which were compliled into the Hartford Consensus Compendium. This compendium has now been released as a Special Communication from the ACS.

In the first of the Hartford Consensus publications, Dr. Jacobs and the author group noted:

“One example of the lifesaving potential of TCCC guidelines is the renewed focus on prehospital tourniquet use. Before TCCC concepts were introduced, military medics were taught that a tourniquet should be used only as a last resort to control extremity hemorrhage. It is not surprising to note that a study of 2,600 combat fatalities from the Vietnam conflict and a second study of 982 fatalities from the early years of conflicts in Afghanistan and Iraq found that the incidences of death from extremity hemorrhage were essentially unchanged, at 7.4% and 7.8%, respectively…..However, after widespread implementation of the tourniquet recommendations from the TCCC guidelines, deaths from extremity hemorrhage became uncommon. A recent comprehensive study of 4,596 US combat fatalities from 2001 to 2011 noted that the incidence of preventable deaths from extremity hemorrhage had decreased remarkably to 2.6%.....The number of US lives saved from this single intervention has been estimated to be between 1,000 and 2,000."

The Hartford Consensus recommended that all professional first responders, to include EMS systems, law enforcement officers, and firefighters, should carry tourniquets and hemostatic dressings while carrying out their professional duties

This was a remarkable rethinking of the long-held position that tourniquet use in the prehospital phase of care for trauma victims should be avoided because it would result in an unacceptable incidence of limb loss due to tourniquet ischemia. The work done by COL John Kragh had clearly proven that this perception was false and that prehospital tourniquets were safe, effective, and lifesaving should the casualty actually have a major vascular injury. The recommendations of the Hartford Consensus were reinforced by the findings of the Prehospital Subcommittee of the American College of Surgeons in 2014. That group, led by Dr. Eileen Bulger, also agreed that the military experience with TCCC in Iraq and Afghanistan had proven tourniquets and hemostatic dressings had been effective in saving limbs and had caused only minimal morbidity when used for short periods of time. The Hartford Consensus was the springboard for the Stop the Bleed program, which was implemented by the ACS with the active support and endorsement of the White House.

Both the everyday trauma that occurs in the U.S. as well as the dramatic increase in terrorist attacks and so-called “active-shooter” incidents create the potential for a great many additional lives to be saved by using TCCC and Stop the Bleed concepts. Public awareness of such events and the ACS and White House advocacy for the Stop the Bleed program is already paying significant dividends in lives saved and has caused an acceleration of the translation of these two lifesaving interventions from the military to the civilian sector.

Two other factors that have also been important in accelerating this translation are the development of the civilian Tactical Emergency Casualty Care (TECC) program, which takes TCCC concepts and tailors them to better meet the tactical considerations that are encountered by law enforcement and firefighters in civilian high threat scenarios. In addition, the educational leadership displayed by The National Association of Emergency Medical Technicians (NAEMT) in offering courses in Prehospital Trauma Life Support, TCCC, and TECC around the world have made tactical medicine training widely available for organization that seek it. These initiatives and many other local, state, and regional efforts have ensured that the advances in prehospital trauma care pioneered by TCCC, the Joint Trauma System, and military medicine are being used to save lives in civilian trauma care practice with increasing frequency, notably by the law enforcement officers and firefighters that the Hartford Consensus Group identified as a previously underutilized source of lifesaving first responder care for trauma victims.

The impact of TCCC on civilian first responder trauma care and its subsequent incorporation into the Hartford Consensus and the White House/ACS Stop the Bleed program was summed up by Hawk:

“Tactical Combat Casualty Care has revolutionized prehospital care, dramatically reduced the incidence of preventable battlefield death, and spurred development of novel devices to arrest hemorrhage, such as junctional tourniquets and the X-Stat hemostatic device. The application of the lessons learned has transitioned to civilian practice. The American College of Surgeons convened senior leaders from the military medical, law enforcement, and emergency medical services communities to explore the civilian application of Tactical Combat Casualty Care in response to active-shooter mass casualty incidents. Those leaders generated the Hartford Consensus, which described a series of critical actions with the acronym THREAT. The second action was hemorrhage control. Launched in October 2015 by the White House, “Stop the Bleed” is a national awareness campaign managed through the Department of Homeland Security.”

References

Bulger EM, Snyder D, Schoelles K, Gotschall C, Dawson D, Lang E, Sanddal ND, Butler FK, Fallat M, Taillac P, et al. An evidence-based prehospital guideline for external hemorrhage control: American College of Surgeons Committee on Trauma. Prehosp Emerg Care. 2014;18(2):163–73.

Butler FK: The Hartford Consensus: A Major Step Forward in Translating Battlefield Trauma Care Advances to the Civilian Sector; J Spec Op Med 2015;15:133-135

Butler FK, Carmona R: Tactical Combat Casualty Care: From the Battlefields of Afghanistan and Iraq to the Streets of America. The Tactical Edge. Winter 2012

Callaway DW. Translating Tactical Combat Casualty Care Lessons Learned to the High-Threat Civilian Setting: Tactical Emergency Casualty Care and the Hartford Consensus. Wilderness Environ Med. 2017 Jun;28(2S):S140-S145.

Callaway D, Robertson J, Sztajnkrycer M. Law enforcement-applied tourniquets: a case series of life-saving interventions. Prehosp Emerg Care. 2015;19:320-327.

Callaway DW, Smith ER, Cain J, Shapiro G, Burnett WT, McKay SD, Mabry R. Tactical emergency casualty care (TECC): guidelines for the provision of prehospital trauma care in high threat environments. J Spec Oper Med. 2011;11(3):104–122

Jacobs LM and the Joint Committee to Create a National Policy to Enhance Survivability from Intentional Mass Shooting Events. The Hartford Consensus IV: A call for increased national resilience. Conn Med J. 2016;80:239-244.

Jacobs LM, Wade DS, McSwain NE, et al. The Hartford Consensus: THREAT, A Medical Disaster Preparedness Concept. J Am Coll Surg. 2013;217:947-953.

Jacobs LM, McSwain NE Jr, Rotondo MF, et al. Improving survival from active shooter events: The Hartford Consensus. J Trauma Acute Care Surg. 2013 Jun;74:1399-1400.

Jerome J, Pons PT, Haukoos JS, Manson J, Gravitz S: Tourniquet Application by Urban Police Officers The Aurora, Colorado Experience. JSOM 2021;21:71-76

Kragh J, Walters T, Westmoreland T, Miller R, Mabry RL, et al: Tragedy into drama: an American history of tourniquet use in the current war. J Spec Oper Med. 2013;13:5-25.

Kragh JF, Walters TJ, Baer, DJ, et al. Survival with emergency tourniquet use to stop bleeding in major limb trauma. Ann Surg. 2009;249(1):1–7.

Kragh JF, Walters TJ, Baer DG, et al. Practical use of emergency tourniquets to stop bleeding in major limb trauma. J Trauma. 2008; 64(2)(suppl):S38–S49.

Levy M, Jacobs L. A call to action to develop programs for bystanders to control severe bleeding. JAMA Surg. 2016;151(12):1103-1104.

Pons P, Jerome J, McMullen J, et al. The Hartford Consensus on active shooters: implementing the continuum of prehospital trauma response. J Emerg Med. 2015;49:878–885.

Reed JR, Carman MJ, Titch FJ, Kotwal RS. Implementation and evaluation of a first-responder bleeding-control training program in a rural police department. J Spec Oper Med. 2018;18(3):57–61.