Casualty Care in the Classroom

“Gunman at Illinois College Kills 5 Students, Wounds 16” —Washington Post

“Our Hearts Are Broken Today” —Chicago Tribune

“Unthinkable” —Tampa Bay Times

“Unspeakable" —San Francisco Chronicle

It’s hard to read the news today without finding headlines such as these that highlight the devastation of an active-shooter attack. A 2013 FBI document, A Study of Active Shooter Incidents in the United States Between 2000 and 2013, concluded active-shooter events are increasing and becoming more lethal.¹ Significant time, resources and funds have been dedicated to training first responders to manage these events, but a gap exists in equipping other “immediate responders” for these threats.

1 bleeding to death

The message above was handwritten on a whiteboard and displayed in the window of Columbine High School as the active-shooter incident played out during that tragic day nearly 17 years ago. The Columbine attack forever altered the law enforcement approach to active-shooter events. Police training and attitudes have been reshaped, and equipment and tactical procedures have evolved to adapt to the threat. Law enforcement agencies are better prepared to respond, but there is another segment of the population impacted by active-shooter events that has not, before now, been effectively engaged to help. This article sets forth how one community chose to make a difference in preparedness by engaging and empowering those closest to the victims to act during a critical incident or attack.

A Troubling Answer

In February 2014, the FBI’s Milwaukee Division facilitated an active-shooter tabletop exercise at the invitation of the Janesville (WI) Police Department. The audience was deliberately chosen to include not only local law enforcement, but also cross-disciplinary, multijurisdictional representatives from all stakeholders who would be impacted by a significant active-shooter event at a local elementary school. Participants included elected and appointed city officials, city and county law enforcement, emergency dispatchers and representatives from the fire department, EMS, public works, transportation services, the district attorney’s office, the coroner’s office, public information officers, emergency managers, school district leaders and members of the local medical community. The purpose of the exercise was to discuss, in depth, how each of the interdependent agencies would function together to prepare for and respond to an active-shooter event.

Several “do-outs” and “take-aways” were identified during the exercise, but there was perhaps nothing more significant than the exchange between Chris Wistrom, DO, associate EMS medical director for MercyRockford Health System’s emergency medical services, and Yolanda Cargile, EdD, director of student services for the Janesville School District, regarding a key question: “What happens for medical care from time of injury to time safe to enter?”

A troubling answer emerged: nothing. Aside from the obligatory CPR classes, teachers and other school personnel had not historically been exposed to lifesaving medical skills training. As a community, exercise participants found this level of preparedness unacceptable. So they set about to change it.

A Multidisciplinary Approach

Under the guidance of Wistrom and Cargile, a core cadre of volunteers was formed, including representatives of law enforcement, local fire/EMS, the school district and the local hospital. The goal was to find a program to bridge the gap from time of injury to the arrival of trained medical responders. Literature searches and best-practices reviews by all volunteers failed to identify easily implemented programs or universally recognized solutions. It became clear a multipronged, multidisciplinary approach was needed. This would ensure trained EMS providers were prepared to enter the “warm zone” more quickly and efficiently, but it would also leverage and engage an entirely new resource—the people already inside the scene—to start lifesaving treatment.

The first prong of the community preparedness program was the full adoption of the rescue task force (RTF). RTF is not a new concept. Ironically, the framework for such a program was outlined in the Winter 2001 edition of The Tactical Edge magazine by two officers from the Beloit (WI) Police Department.² The concepts in their article, “Confined Threat Escort Tactics,” were not widely recognized or adopted at the time. In October 2013, however, the International Association of Fire Chiefs (IAFC) adopted a position paper that identified support for a rescue task force, and that paper is credited with significantly helping the movement progress.³ The core group set about planning to expose all first-responding agencies within MercyRockford Health System’s service area to the RTF concept.

The second prong of the community-based approach was to create a training program to teach teachers, administrators and other school staff the critical lifesaving skills not found in the school handbook. Once trained, lay personnel would become well-qualified “first” first responders, a population increasingly referred to as immediate responders. With it taking only minutes to bleed to death from a severe arterial injury,⁴ no RTF would be able to make the difference for the most critically injured. But the immediate responders would already be there!

Once the need was identified, the challenge became creation of the right program. In that quest, some age-old questions had to be answered: Who? When? Why? Where? What? And, dauntingly, how?

Identifying who to train was fairly straightforward: School personnel were the target audience for the immediate implementation of the education program. It made sense that those already inside the situation would make the ideal first line of defense. But who was best positioned to provide the training?

Almost immediately after deciding to tackle this project, the core group identified that it wanted to create a model program that could be implemented in any community. This led to the development of a train-the-trainer model that could be taught to public safety providers anywhere. After all, the ideal trainers for teachers in Anytown, USA, are the public safety providers who serve Anytown, USA.

Because many public safety providers have received some active-shooter training, the new program was designed to complement other training programs that focus on the tactics of a response. The new program would not address or debate active-shooter response tactics—it would focus on what other programs didn’t address: core lifesaving medical skills that will make a difference prior to the arrival of skilled public safety providers.

When to conduct the training had to be considered. School district personnel identified that all school districts utilized some type of staff in-service day. Some were in the fall, some were in the spring, and all had limited time due to other competing demands. The core team determined if the training could be kept to 45 minutes, it could be accomplished in nearly any in-service training window. In fact, the Janesville School District utilized a 45-minute window for in-service topics every week. To ensure consistency, a short video was developed that provided an overview of the training program. It was designed to be made available to the target audience via an e-mail link sent the day prior to training to introduce staff to the topic. The training material was streamlined so the day of training included only a 10-minute lecture, followed by 35 minutes of hands-on skill-building exercises.

The why aspect became fairly apparent following an extensive review of medical literature. The research, including a review of the Committee for Tactical Emergency Casualty Care’s TECC guidelines, showed the greatest number of preventable deaths in penetrating trauma are either directly or indirectly related to bleeding.⁵ The sooner massive bleeding can be slowed or stopped, the higher the likelihood of survival. With that in mind, hemorrhage control became the cornerstone of the new training program.

The group evaluated where the program should be implemented, and it made sense to start in the Janesville schools. The program had to be universally applicable, however, and it was designed to work in any part of the country and any setting—schools, hospitals, businesses, public venues—where attacks could occur. Not unlike CPR and AED training programs, the hemorrhage control program was intended to be easy to implement anywhere. The large-scale goal was to teach as many people as possible how to stop life-threatening bleeding, whether by use of commercially available products or through improvisation with tools at hand.

In addition to hemorrhage control, the group evaluated what other training topics could be addressed by the program. They arrived at hemorrhage control as the primary goal, followed by management of other preventable causes of death, including simple airway management and use of the recovery position.⁵

Perhaps the greatest amount of time spent in program development was determining how to deliver the training content. The team had to address the realities of whether those to be instructed would be amenable to the topic. They had to identify what supplies and equipment to obtain, how to finance them, and whether there was an understanding of the need for the training outside the ranks of the professional responder community. Additionally, if training materials and actual medical supplies could be obtained for deployment, were there practical limitations on what could be placed in the schools based on state law or school policies?

The multidisciplinary nature of the group again proved essential to resolving these questions. A quick straw poll of school employees identified that they indeed wanted the education. Surprisingly, many of those asked expressed substantial fear that they did not know how to act to save a life. Several shared that they’d considered changing professions because the anxiety they had surrounding these crises increased significantly each time an active-shooter event was reported somewhere in the nation.

With respect to the overall cost of implementation, the local fire and police departments quickly volunteered the time necessary to do the training. As a result, costs were limited to those necessary to acquire training aids and materials, followed by costs associated with medical supplies to be deployed to the schools in casualty care kits that would be available in an emergency. The core group determined it made the most strategic sense to deploy one casualty care kit to each classroom. Placing kits in hallways or office areas would limit access to the lifesaving tools in a lockdown situation, and students or staff could be exposed to danger if they tried to retrieve them from a central location. The dispersed-deployment plan required substantially more kits to cover a single school, so the overall cost of each individual kit was an important consideration (see sidebar).

Implementation

To date, the Casualty Care in the Classroom program focused on stopping life-threatening bleeding has been presented to more than 3,000 school employees in Southern Wisconsin and Northern Illinois. Surveys sent to participants before, right after and at one year after training show the training to be effective. The training substantially increases confidence in participants’ abilities to stop the bleeding. It has also served to better inform school personnel about the roles of law enforcement and EMS at the scene of active-shooter and other mass-casualty events. Most important, the training did not change participants’ perspectives on how likely an active-shooter event was to happen in their schools. In fact, the training reduced fear, increased confidence and relieved anxiety.

Since inception of the program, hundreds of casualty care kits have been fielded to schools throughout MercyRockford Health System’s service area. Funding sources for the kits have included private donations, grant sources, community foundations, direct school funding and law enforcement seizure program funds. “We are doing this because it is the right thing to do,” says MercyRockford Health System CEO Javon Bea.

The Casualty Care in the Classroom program has proven successful because it utilized a multidisciplinary, community-based approach to problem solving. The core group enjoyed incredible support from MercyRockford Health System and hospital administration, which partnered with the team to provide the education and materials at as low a cost as possible.

Since the inception of the Casualty Care in the Classroom program over two years ago, several significant strides have been made in immediate responder care. Two of the more notable include the Hartford Consensus Third Compendium⁶ and initiation of the White House “Stop the Bleed” campaign.⁷ None of these directives or programs, including the Casualty Care in the Classroom program,⁸ can prescribe a one-size-fits-all approach to hemorrhage control, but each demonstrates progress toward helping this country stop the bleeding.

For more information:

• Hartford Consensus Third Compendium: www.facs.org/~/media/files/publications/bulletin/hartford%20consensus%20compendium.ashx;
• Stop the Bleed: www.dhs.gov/stopthebleed;
• MercyRockford Health System Casualty Care in the Classroom: www.mercycasualtycarekits.com.

Kit Equipment Selection

The initial consideration was to utilize the same type of equipment traditionally carried by SWAT operators and tactical medics. This includes Israeli bandages, SOF or C-A-T tourniquets, hemostatic gauze, chest seals and needle-decompression devices. The training requirements to teach and maintain the skills to implement the equipment were problematic, however, and acquisition of the materials proved cost-prohibitive after research determined each kit would cost approximately $120!

In an effort to make the most cost- and training-effective, sustainable kit possible, the core group decided the contents of the kit would at a minimum include gloves, ACE wrap, rolled gauze, SWAT-T tourniquet and instructional card. Research concluded all those items could be acquired and packaged within a plastic bag for a total unit cost of under $20.

The ACE wrap combined with gauze could serve as an excellent pressure dressing and be used alone as a makeshift tourniquet. The rolled gauze is ideal for packing wounds. Plastic packaging material, the plastic bag or the gloves could all be used as excellent makeshift chest seals. The SWAT-T had several advantages as well: Instructions for application are printed clearly on it, it requires no fine motor skills to apply, and it requires less strength to apply than a SOF or C-A-T. Additionally, the SWAT-T could accommodate any size extremity (important for elementary schools with pediatric patients), be cut for use by multiple patients, and be used as an excellent pressure dressing. The SWAT-T was much less expensive than traditional windlass tourniquets and had about the same shelf life.

One identified limitation with the SWAT-T was that self-application could be difficult, especially without consistent practice. In the final analysis, however, to achieve deployment of the maximum number of kits at an acceptable cost, the identified materials represented the minimal supplies necessary for effectiveness. Additional supplies could be added to these kits if needs or gaps were later identified.

Special thanks to the following for their contributions to this article: Todd Daniello, MD; Sean Marquis, MD; John Pakiella, DO; Rick Barney, MD; Rodney VanBeek, MD; Capt. Tom Brunner, EMT-P; Scott Formankiewicz, EMT-P; Tony Cellitti, EMT-P; Sgt. Michael Blaser; Officer Jason Kelley; Chief Deputy Scott Meyers; and Yolanda Cargile, EdD.

References

1. Blair JP, Schweit KW. A Study of Active Shooter Incidents, 2000–2013. Texas State University and Federal Bureau of Investigation, U.S. Department of Justice, Washington, DC, 2014.

2. Anderson D, Kelley J. Contained Threat Escort Tactics. The Tactical Edge, Winter 2001.

3. www.iafc.org/IAFC-position-Active-Shooter-and-Mass-Casualty-Terrorist-Event.

4. Blaivas M, Shiver S, Lyon M, Adhikari S. Control of hemorrhage in critical femoral or inguinal penetrating wounds—an ultrasound evaluation. Prehosp Disaster Med, 2006 Nov–Dec; 21(6): 379–82.

5. Kotwal RS, Montgomery HR, Kotwal BM, et al. Eliminating preventable death on the battlefield. Arch Surg, 2011 Dec; 146(12): 1,350–8.

6. Jacobs LM Jr., Joint Committee to Create a National Policy to Enhance Survivability From Mass-Casualty Shooting Events. The Hartford Consensus III: Implementation of Bleeding Control. Bulletin of the American College of Surgeons, https://bulletin.facs.org/2015/07/the-hartford-consensus-iii-implementation-of-bleeding-control/.

7. Department of Homeland Security. Stop the Bleed, www.dhs.gov/stopthebleed.

8. Mercy Casualty Care Program. Introducing…the Mercy Casualty Care Program, www.mercycasualtycarekits.com.

Special Agent G.B. Jones is currently assigned to the FBI, Milwaukee Division. As an assistant special agent in charge, Jones commanded the FBI Milwaukee SWAT and crisis management teams and oversaw the division’s active-shooter training program. He served as the FBI’s on-scene commander during the Azana Spa shooting in Brookfield, WI, in 2012 and at a mass shooting at Northern Illinois University in DeKalb, IL, in 2008. Jones is an EMT in the FBI EMS program.

Karen Schulte, EdD, is superintendent of the Janesville (WI) School District.

James J. MacNeal, DO, is the EMS medical director for the Mercy Health System, as well as multiple EMS and TEMS agencies in both Illinois and Wisconsin. His background includes 27 years in law enforcement, fire and EMS. He is board certified in emergency medicine and EMS.

Christopher Wistrom, DO, started his career in EMS as a volunteer in his home town. He has worked in private, hospital-based and fire-based EMS as an EMT and paramedic. He is associate EMS medical director for the Mercy Health System in Wisconsin.